Conditions: HIV-1 Infection
Allocation: NON_RANDOMIZED | Intervention model: PARALLEL
Enrollment: 195
Healthy volunteers: no

Brief summary:
The study was done to:

* Start antiretroviral therapy (ART) early in those recently or acutely infected with HIV-1
* See how starting ART as soon as the infection is found affects the amount of HIV-1 in blood and how well the body fights the HIV-1 infection
* Look at the amount of HIV-1 DNA (genetic material for HIV-1) seen in CD4+ T-cells (infection-fighting cells in blood) after 48 weeks of ART
* See how early treatment for HIV affects the numbers of HIV-1 infection fighting cells (CD4+ and CD8+ T-cells) in blood

Detailed description:
This was a Phase II, prospective, open-label two-step study to measure the effects of early ART on the establishment of HIV-1 reservoir and HIV-1-specific immunity. Participants were enrolled if they fulfilled the inclusion criteria for acute HIV-1 infection (AHI) diagnosis within 7 days prior to entry and had an enrollment visit with the immediate initiation of ART. Plasma and serum samples for Fiebig staging were collected at the time of ART initiation.

Participants were followed for up to 216 weeks (72 weeks on Step 1 and 144 weeks on Step 2). Evaluations at weeks 2 and 8 on Step 1 were performed via telephone.

The Fiebig stage-classification system was used to characterize the progression from HIV-1 exposure to HIV-1 seroconversion at the time of ART initiation. In this study, the five Fiebig stages of interest were simplified into three study groups as described below (based on HIV-1 antibody diagnostic profile at time of ART initiation).

The primary analysis was based on Step 1. Step 2 was added to the study for long term follow-up. The rationale for the extended follow-up period was to expand the number of available participants for future therapeutic and cure studies without the burden of frequent visits and the cost of study-provided laboratory testing.

Group 1: Fiebig I/II (non-reactive HIV-1 antibody)

Group 2: Fiebig III/IV (reactive HIV-1 antibody and negative or indeterminate results on the Western Blot (WB) or Geenius HIV-1/HIV-2)

Group 3: Fiebig V (reactive HIV-1 antibody and positive WB or Geenius HIV-1/HIV-2 without p31 band)

Although participants in Fiebig VI (positive WB or Geenius HIV-1/HIV-2 with p31 band) were not specifically targeted for enrollment in this study, it was possible that a small number of participants would be determined to be in Fiebig VI (positive Western blot or Geenius HIV-1/HIV-2 with p31 band) based on analysis of the entry samples. Participants who were determined to be in Fiebig VI were followed on the study for no more than 24 weeks on Step 1, allowing ample time for them to pursue alternative sources for ART. Enrolled participants without HIV or in Fiebig VI were replaced.

The study-provided regimen was single tablet regimen elvitegravir/cobicistat/emtricitabine/tenofovir alafenamide (EVG/COBI/FTC/TAF) or bictegravir/emtricitabine/tenofovir alafenamide (BIC/FTC/TAF). Other non-study-provided antiretroviral (ARV) regimens were also allowed for participants who were pregnant, breastfeeding, or unable/unwilling to take EVG/COBI/FTC/TAF or BIC/FTC/TAF, or for participants whose local health care/primary care provider preferred starting a different initial ARV regimen.

Arms:
arm 1: Participants enrolled during Fiebig stages I or II (non-reactive HIV-1 antibody). arm 2: Participants enrolled during Fiebig stages III or IV (reactive HIV-1 antibody and negative or indeterminate results on the Western blot or Geenius HIV-1/HIV-2). arm 3: Participants enrolled during Fiebig stage V (reactive HIV-1 antibody and positive Western blot or Geenius HIV-1/HIV-2 without p31 band).

Interventions: intervention 1: elvitegravir/cobicistat/emtricitabine/tenofovir alafenamide or bictegravir/emtricitabine/tenofovir alafenamide or other medically-appropriate FDA-approved antiretroviral therapy
Intervention descriptions: intervention 1: Participants received one tablet of elvitegravir 150mg/cobicistat 150mg/emtricitabine 200mg/tenofovir alafenamide 10mg by mouth daily with food or one tablet of bictegravir 50mg/emtricitabine 200mg/tenofovir alafenamide 25mg by mouth daily with or without food. Other non-study-provided ARV regimens were allowed for participants who were pregnant, breastfeeding, or unable/unwilling to take EVG/COBI/FTC/TAF or BIC/FTC/TAF, or for participants whose local health care/primary care provider preferred starting a different initial ARV regimen.

Protocol document:
ICF_000.pdf: 
 
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INFORMED CONSENT DOCUMENT 
 
Project Title: 
A5354: Effect of Antiretroviral Treatment Initiated During Acute HIV-1 Infection 
on Measures of HIV-1 Persistence and on HIV-1-Specific Immune Responses 
 
 
Principal Investigator: 
Rachel Presti MD PhD 
 
Research Team Contact: 
DeMarco Shaw RN or Michael Royal RPh 
 
 
This consent form describes the research study and helps you decide if you want to participate.  It 
provides important information about what you will be asked to do during the study, about the risks and 
benefits of the study, and about your rights and responsibilities as a research participant. By signing this 
form you are agreeing to participate in this study. 
• You should read and understand the information in this document including the procedures, 
risks and potential benefits.  
• If you have questions about anything in this form, you should ask the research team for more 
information before you agree to participate.   
• You may also wish to talk to your family or friends about your participation in this study. 
• Do not agree to participate in this study unless the research team has answered your 
questions and you decide that you want to be part of this study.  
 
 
WHAT IS THE PURPOSE OF THIS STUDY? 
 
This is a research study.  We invite you to participate in this research study because: 
1. You are acutely infected with the human immunodeficiency virus type 1 (HIV-1, the virus that 
causes AIDS). Acutely infected means that you are newly infected with HIV.  
2. You are willing and able to start taking antiretroviral therapy (ART, anti-HIV drugs) right away. 
 
The purpose of this research study is to:  
• start ART early in those recently or acutely infected with HIV-1 
• see how starting ART as soon as the infection is found affects the amount of HIV-1 in your 
blood and how well your body fights the HIV-1 infection 
• look at the amount of HIV-1 DNA (genetic material for HIV-1) seen in CD4+ T-cells (infection-
fighting cells in your blood) after 48 weeks of ART  
• see how early treatment for HIV affects the numbers of HIV-1 infection fighting cells (CD4+ 
and CD8+ T-cells) in your blood 
 
WHAT WILL HAPPEN DURING THIS STUDY? 
 
Screening visit 
If you decide to join this study, you will first need to be screened for the study to make sure that you 
qualify to continue. After you have read and signed the consent form, the study staff will check your 


 
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medical records for available documentation of your HIV-1 diagnosis; for instance, whether you are 
recently or acutely infected with HIV-1 to make sure that you meet the requirement for continuing in the 
study. You will also be asked how to be contacted in case you miss a visit or there are problems with 
your tests, and whether you give the study team permission to contact you. 
 
Entry Visit 
If your records show that you are eligible to enter the study you may enter on the same day or within 7 
days of this visit. 
 
You will start taking ART at study entry. At study entry, a sample of your blood will be tested to 
confirm your HIV-1 infection. At the time of starting ART, an additional sample of your blood will be 
tested to see how far along you are with your HIV-1 infection; this is called Fiebig staging. In this study, 
there are three groups determined by Fiebig staging (Fiebig I/II, Fiebig III/IV and Fiebig V). Based on 
your medical records of HIV testing and the results from the day that you start the HIV medications, the 
study team will determine which study group you will be included in. Both you and your doctor will 
know which drugs you are taking. The study staff will work with you to make sure you are taking your 
medication correctly. 
 
The study will provide a single tablet that contains 4 different drugs. Three of these drugs treat HIV, and 
one is a drug that increases the levels of one of the anti-HIV drugs. The names of these drugs, which will 
be provided as a single tablet regimen, are: elvitegravir/cobicistat/emtricitabine/tenofovir alafenamide 
(EVG/COBI/FTC/TAF) and has been approved by the US Food and Drug Administration.   
 
If you are not able to take the study-provided medicine, then you will be allowed to take the best ART 
available to you, as prescribed by your primary care doctor. These non-study-provided ART must be 
obtained locally.  
 
The table below details what will happen at each visit.  
 
 
 


 
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prn = if suspected 
 
NOTES:  
• If your laboratory tests from entry show that you do not qualify to continue in the study, the study 
staff will tell you to stop all ART. You will be asked to complete the discontinuation evaluations, 
and your follow-up will end.   
• After you enter the study, if your blood test shows that you have had HIV longer than expected at the 
time of entry, then your follow-up and HIV study treatment will end at week 24. Your doctor will 
tell you the results of the tests by week 12 so you will have time to pursue HIV treatment outside of 
the study.  
• If you are eligible to join the study, you will enter the study and be placed into a group. At this visit, 
you will start taking ART. If you are unable or unwilling to take the study-provided drug, then you 
must have access to and can begin to take an alternative ART in order to enter the study.  
• Large volume blood collection (200 mL, approximately 13.5 tablespoons, of blood) will be done at 
entry. 
Procedure 
Entry 
Wk 
1 
Wk 
2 
Wk 
4 
Wk 
8 
Wk 
12 
Wk 
24 
Wk 
36 
Wk 
48 
Wk 
49 
Wk 
60  
Wk 
72 
Special Visit 
Leaving or 
Stopping 
the Study 
Early 
HIV-1 infection 
confirmed and 
Fiebig stage 
testing 
√ 
 
 
 
 
 
 
 
 
 
 
 
 
 
Group 
assigned and 
ART started 
√ 
 
 
 
 
 
 
 
 
 
 
 
 
 
Physical exam 
√ 
√ 
 
√ 
 
√ 
√ 
√ 
√ 
√ 
√ 
√ 
 
√ 
Blood 
collected 
√ 
 
 
√ 
 
√ 
√ 
 
√ 
√ 
√ 
√ 
√ 
√ 
Pregnancy 
test 
√ 
prn  
prn 
 
prn 
prn 
prn 
prn 
prn 
prn 
prn 
 
√ 
Resistance 
test 
√ 
 
 
 
 
 
 
 
 
 
 
 
√ 
 
Urine collected 
√ 
 
 
 
 
 
 
 
 
 
 
 
 
√ 
Telephone 
follow-up  
 
 
√ 
 
√ 
 
 
 
 
 
√ 
 
 
Adherence 
support 
√ 
√ 
 
√ 
 
√ 
√ 
√ 
√ 
 
√ 
√ 
√ 
 
Large volume 
blood draw  
√ 
 
 
 
 
 
 
 
 
 
√ 
 
 
Optional 
Leukapheresis 
 
 
 
 
 
 
 
 
 
 
√ 14T* 
 
 
Optional 
Sigmoid gut 
biopsy 
 
 
 
 
 
 
 
 
 
 
√ 
 
 
Optional 
lumbar 
puncture 
 
 
 
 
 
 
 
 
 
 
√ 
 
 
Approximate 
amount of 
blood 
t=teaspoon 
T=tablespoon 
16T  
1 t 
 
5T 
 
6T 
6T 
3t 
16T 
4T 
5t 
5t 
2T 
2t 
In mls 
231 
3 
0 
79 
0 
83 
83 
10 
231 
63 
23* 
23 
20 
9 


 
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• If you stop taking your ART for 7 or more days in a row, the last peripheral blood mononuclear cells 
(PBMC, cells separated from the blood taken from you) and plasma (the liquid part of blood taken 
from you) collection will be done at week 48.  
• Blood collection-Blood will be collected from you for various tests during the study. These include: 
routine safety laboratory tests, HIV-1 viral load (a test that shows how much HIV-1 is in your 
blood), CD4+ T-cell count (a test that shows how many infection-fighting cells you have in your 
blood), and liver function tests. At entry and at the confirmatory visit to check whether your ART 
regimen has failed, a sample will be collected for resistance testing (a test that shows whether the 
ART is working for you). Routine PBMC and plasma storage will be done.  
• Human genetic testing-Some of your blood will be tested to see whether the ART you are taking are 
making a difference by looking at your immune response (levels of infection fighting cells, CD4+ 
and CD8+ T-cells, in your blood) or whether development of resistance to ART is associated with 
different genes. Genes are a unique combination of molecules (called DNA) that we inherit from our 
parents. There are millions of tiny differences in our genes that determine things like our height or 
the color of our eyes. Some of these differences may make some people more or less likely to 
develop certain diseases or conditions or to have certain characteristics. You will not receive the 
results of these studies because they will be done in the future. 
• Pregnancy testing-If you are a woman who is able to become pregnant, then you may be asked to 
give a small urine or blood sample for a pregnancy test.  
• HIV-1 resistance testing-Your blood will be used to see which ART might work best for you. 
NOTE: If resistance testing was done as part of routine care, the study doctor may review these 
results to make sure that your current ART is still the best for you. 
• Urine collection-You will be asked to provide a small amount of urine that will be used in safety 
tests. 
• Primary endpoint determination-At week 48, you will be asked to give blood samples for testing to 
determine whether you met the main goal of the study by looking at the total amount of HIV genetic 
material in infection-fighting cells at study week 48 (also known as the primary endpoint).  
• Site follow-up with participants via telephone-You will be asked about how you have been feeling 
and how well you are remembering to take your ART.  
• Adherence support-Everyone will get some adherence support from the site staff. This means that 
study staff will explain to you in detail how to take the medications and help you find ways to take 
the medications correctly. 
 
If you enter this study, you will need to come for study visits up to nine times in the first year, of which 
two of these visits (wks. 2, 4) will be done by telephone. If during these telephone visits, the study staff 
determines that you should be seen in person, you will be asked to go to the clinic.  
 
In the next year, you will have up to two clinic visits (wks. 60, 72) that will include the study staff 
contacting you by telephone the day after completing the optional procedures (gut biopsy and/or lumbar 
puncture). You will be notified by the study staff of when to expect to receive these telephone calls 
before you are actually called. Most clinic visits will last about 1 hour. The study staff will tell you how 
long each visit will last.  
 
You may need to come to the clinic for extra visits if you develop side effects or if you need to switch to 
non-study-provided ART or if the level of HIV in your blood increases after it has been undetectable. 


 
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During the study, you will receive results, when they are available, from any routine tests that are done 
during the study. 
 
 
 
Optional procedures 
 
These additional, optional procedures include leukapheresis or large volume blood collection, gut biopsy 
by flexible sigmoidoscopy, and lumbar puncture. These will be done at weeks 60 or 72. You will not 
receive the results of these procedures because they will be done in the future. No matter what you 
decide, it will not affect your participation in the study.  
 
 
Leukapheresis or Large Volume Blood Collection 
The leukapheresis procedure will be performed at the Barnes-Jewish Hospital Pheresis Center on the 4th 
floor of the Center for Advanced Medicine (CAM). We will take you over to the Pheresis Center for an 
assessment before we can schedule the procedure. This will be performed by Pheresis staff if we can 
continue we will schedule the procedure. The procedure will take between 1 and 3 hours and the full 
visit will last about four hours. You will have to remain in a semi-reclining or reclining position for the 
most of this time. 
 
Leukapheresis involves taking some of your blood, processing it, and giving most of it back to you. This 
will be done by inserting a needle attached to sterile tubing in one arm, and first sending your blood 
through a machine. This machine spins your blood to separate the red blood cells (cells that carry 
oxygen), the white blood cells (cells that fight infection) and the platelets (cells that help form clots). 
The white blood cells will be kept for testing. All the rest of your blood will be returned to your body 
through another needle and tube in your other arm. Not all of your white blood cells are removed and 
your body will make more white cells within a few days. Losing the number of white blood cells that are 
collected does not pose a danger to you or to your health. 
 
I agree to participate in optional leukapheresis or large volume blood collection 
 
_____ Yes  
_____ No 
Initials 
Initials 
 
Gut Biopsy 
The gut biopsy procedure will be performed at the Barnes Jewish Hospital Endoscopy Suite 8th floor of 
the Center for Advanced Medicine (CAM). The procedure will take about 1 hour and the full visit 
should last about 90 minutes.    
 
A gut biopsy is a medical procedure that involves removing a sample of tissue taken from your gut to 
closely examine it. This will be performed following the local standards of care for this procedure. Just 
before the gut biopsy, you may have an enema (a salt water rinse that will flush out your lower bowel). 
Next, a lubricated flexible tube will be placed into your rectum. Using this instrument, the doctor will 
examine the inside of your intestine and will collect samples of tissue for testing.  
 


 
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You should not have anal sexual intercourse or insert anything into your rectum (including medications 
of any kind) for 3 days before and for 7 days after the procedure. The study or clinic staff will call you 
within 1 week after the procedure to check on how you are feeling.  
 
I agree to participate in optional gut biopsy by flexible sigmoidoscopy 
 
_____ Yes  
_____ No 
Initials 
Initials 
 
Lumbar puncture 
 
You should drink plenty of fluids the day before the lumbar puncture procedure. The procedure will be 
performed at the AIDS Clinical Trials Unit (ACTU).  On the day of the lumbar puncture, you will have 
a brief physical exam. Then you will be asked to lie down on your side or to sit ‘backwards’ in a chair 
(so that you are facing the back of the chair). An area of skin on your lower back will be sterilized with 
fluid. You will get an injection to numb the skin in the sterilized area. You may feel a burning sensation 
from the fluid that is injected.  When the area is numb, the doctor will insert a thin needle between two 
of the bones in your spine. A small amount of fluid will be collected through the needle. The entire 
lumbar puncture procedure to this point will take about 30 minutes.  
 
After the CSF (cerebrospinal fluid) collection, you may be asked to lie flat for up to 30 minutes to 
reduce the chance that you will get a headache. You should limit your physical activity for the remainder 
of the day. 
 
I agree to participate to optional lumbar puncture 
 
_____ Yes  
_____ No 
Initials 
Initials 
 
 
If you have to stop taking both study-provided and non-study-provided ART 
During the study: 
If you must stop taking ART for 7 or more days in a row while on study, you will be asked by the study 
staff to return to the clinic to have a repeat HIV-1 viral load test that will check whether your ART 
regimen is working. This test is called a virologic failure (VF) confirmatory test. If the confirmatory test 
results show that your ART regimen is working for you, then you will remain in the study for continued 
follow-up and no more PBMC and plasma collection will be done after week 48. If the test results show 
that your ART regimen has failed, then you will be asked to complete the discontinuation evaluations 
before having to stop the study medication and being taken off the study. The study staff will discuss 
other options that may be available to you.  
 
After the study: 
After you have completed the study, the study will not provide you with study drugs. The study staff 
will talk with you about your choices. You and your doctor will decide what treatment you should have, 
and the study staff will discuss with you how you may be able to obtain ART after the study ends.  
 


 
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If you do not enroll into the study 
After signing this consent form, if you decide not to take part in this study or if you do not meet the 
eligibility requirements, the study team 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, HIV-related blood test results) information is being collected 
from you so that the AIDS Clinical Trials Group (ACTG) researchers may help determine whether there 
are patterns or common reasons why people do not join a study. 
 
Will you save my samples or research data to use in future research studies?  
As part of this study, we are obtaining blood samples from you. We would like to use these blood 
samples for studies going on right now as well as studies that are conducted in the future.  These studies 
may provide additional information that will be helpful in understanding HIV, or other diseases or 
conditions, including research to develop investigational tests, treatments, drugs or devices that are not 
yet approved by the U.S. Food and Drug Administration.  It is unlikely that what we learn from these 
studies will have a direct benefit to you.  There are no plans to provide financial compensation to you 
should this occur.  By allowing us to use your blood samples you give up any property rights you may 
have in the blood samples. 
 
If you agree, some of your blood will be saved (with protectors of identity) and tested in the future to see 
how your own genes can help to show how your immune system and/or virus will respond to the ART, 
either successfully or unsuccessfully. You will not receive the results of these studies because they will 
be done in the future. This future research may focus on one or more genes to study the differences in 
specific genes or small groups of genes in people who have HIV when compared to people who do not 
have HIV. Future research with your blood may also attempt to sequence large parts of your genome or 
even your entire genome. These types of sequencing provide detailed descriptions of your DNA and 
result in the creation of information that is as unique to you as your fingerprint.  
 
We will share your blood with other researchers. They may be doing research in areas similar to this 
research or in other unrelated areas.  These researchers may be at Washington University, at other 
research centers and institutions, or industry sponsors of research.  We may also share your research data 
with large data repositories (a repository is a database of information) for broad sharing with the 
research community.  If your individual research data is placed in one of these repositories only 
qualified researchers, who have received prior approval from individuals that monitor the use of the 
data, will be able to look at your information.   
 
If you change your mind and do not want us to store and use your blood samples for future research you 
should contact the research team member identified at the top of this document.  The blood samples will 
no longer be used for research purposes. However, if some research with your blood samples has already 
been completed, the information from that research may still be used. Also, if the blood samples has 
been shared with other researchers it might not be possible to withdraw the blood samples to the extent it 
has been shared. 
 
My blood samples may be stored and used for future research as described above. 
 
_____ Yes 
_____ No 
Initials 
Initials 


 
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My blood samples may be shared with other researchers and used by these researchers for the 
future research as described above. 
 
_____ Yes  
_____ No 
Initials  
Initials 
 
My blood samples may be stored and used for genetic testing as described above. 
 
_____ Yes 
_____ No 
Initials 
Initials 
 
HOW MANY PEOPLE WILL PARTICIPATE? 
 
Approximately 6 people will take part in this study conducted by investigators at Washington 
University.  About 150 people (men and women age 18 years and older) who have acute HIV-1 
infection will take part in this study nationwide. 
 
HOW LONG WILL I BE IN THIS STUDY? 
 
If you agree to take part in this study, your involvement is dependent on your Fiebig score. If you are 
determined to be in Fiebeig 1-V you will be seen at will be seen at 1 week, 4 weeks, 12 weeks, and 24 
weeks after entering the study and then at 48 weeks and thereafter at weeks 60 and 72. If you are 
determined to be Fiebig VI you will be seen at 1 week, 4 weeks, 12 weeks, and your final visit will be at 
week 24. 
 
WHAT ARE THE RISKS OF THIS STUDY? 
 
You may experience one or more of the risks indicated below from being in this study. In addition to 
these, there may be other unknown risks, or risks that we did not anticipate, associated with being in this 
study.  
 
Some risks described in this consent document, if severe, may cause death.  
 
Risks of Social Harm 
Although the study site will make every effort to protect your privacy and confidentiality, it is possible 
that other people could find out that you are in a study and this could cause problems for you. For 
example, other people might figure out that you are infected with HIV-1. If this happens, you could be 
treated unfairly or you could have problems being accepted by other family members, friends, and/or the 
community. 
 
Risks of Drawing Blood and Large Volume Blood Collection  
Taking blood may cause some discomfort, lightheadedness, bleeding, swelling, or bruising where the 
needle enters the body, and in rare cases, fainting or infection.  
 
 


 
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Risks Related to Pregnancy 
The ART in this study may be unsafe for unborn babies. If you are having sex that could lead to 
pregnancy, you must agree not to become pregnant or to attempt to make a woman pregnant.  
 
Because of the risk involved, you and your partner must use at least one effective method of birth 
control. You must continue to use birth control while receiving study drugs.  
 
Remember: If you are having sex, you need to use condoms to prevent transmitting your HIV-1 
infection to others.  
 
Approved methods of birth control are listed below. The study staff will talk with you about your 
choices. 
• Birth control medications that prevent pregnancy given as pills, shots, or placed on or under the skin  
• Male or female condoms with or without a cream or gel that kills sperm   
• Diaphragm or cervical cap with a cream or gel that kills sperm   
• Intrauterine device  
 
If you can become pregnant, you must have a pregnancy test, and the test result must be available before 
you can start ART. If you think you may be pregnant at any time during the study, you must tell the 
study staff right away. If you become pregnant during the study, you will no longer be able to 
participate. However, the study staff may contact you to ask you if you agree to allow us to collect 
information on your pregnancy and outcome. You will be asked to sign a separate consent form for this. 
The study staff will talk to you about your choices.  
 
Risks of ART  
All ART medications can have side effects. The drug regimen provided in this study may have side 
effects. Listed below are the more serious or common side effects that may be related to the study-
provided drugs. Please note that these lists do not include all the side effects seen with the study-
provided drugs. The staff will be able to tell you which are the most serious side effects. They will also 
be able to tell you what to do if you have any of these side effects. If you have questions concerning the 
additional study-provided drug side effects, please ask the medical staff at your site. 
 
Emtricitabine (FTC) 
The following side effects have been associated with the use of FTC: 
Less Likely 
• 
Headache 
• 
Dizziness 
• 
Tiredness 
• 
Inability to sleep, unusual dreams 
• 
Loose or watery stools 
• 
Nausea or vomiting  
• 
Abdominal pain 
• 
Rash, itching, which sometimes can be a sign of an allergic reaction 
• 
Darkening of the skin on the palms of the hands and/or soles of the feet 
• 
Increased cough 


 
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• 
Runny nose  
• 
Abnormal liver function tests, which could mean liver damage, and can cause symptoms such as 
fatigue and yellowing of the eyes and skin 
• 
Increases in pancreatic enzyme (a substance in the blood), which could mean a problem with the 
pancreas  
• 
Increased triglycerides (a type of fat found in the blood) 
• 
Increased creatine phosphokinase (a substance found in the blood), which could mean muscle 
damage 
 
NOTE: If you are infected with both hepatitis B and HIV-1, your liver function tests may increase and 
symptoms caused by hepatitis may get worse if you stop FTC. 
 
Lactic acidosis (elevated lactic acid levels in the blood) and severe hepatomegaly (enlarged liver) with 
steatosis (fatty liver) that may result in liver failure, other complications, or death have been reported 
with the use of antiretroviral nucleoside analogues, such as FTC, when used alone or in combination. 
The liver complications and death have been seen more often in women on these drug regimens. Some 
nonspecific symptoms that might indicate lactic acidosis include: unexplained weight loss, stomach 
discomfort, nausea, vomiting, fatigue, cramps, muscle pain, weakness, dizziness, and shortness of 
breath.  
 
Some side effects of FTC may not need any medical attention. As your body gets used to the medicine, 
these side effects may disappear.  
 
Tenofovir Alafenamide (TAF) 
The following side effects have been associated with the use of TAF: 
Less Likely 
• 
Nausea, vomiting, gas, loose or watery stools   
• 
Generalized weakness 
• 
Dizziness  
• 
Depression 
• 
Headache 
• 
Abdominal pain  
• 
Worsening or new kidney damage or failure, which can cause fatigue, nausea, and loss of appetite 
• 
Inflammation or swelling and possible damage to the pancreas (which can cause pain in the upper 
abdomen) and liver (which can cause a loss of appetite, fever, tiredness, and muscle and joint aches) 
• 
Shortness of breath  
• 
Rash  
• 
Allergic reaction: symptoms may include fever, rash, nausea, vomiting, loose or watery stools, 
abdominal pain, achiness, shortness of breath, a general feeling of illness, or a potentially serious 
swelling of the face, lips, and/or tongue 
• 
Bone pain and bone changes such as thinning and softening, which may increase the risk of breakage  
• 
Muscle pain and muscle weakness 
• 
Sleeping problems 
 
 
 


 
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NOTES:  
• If you are infected with both hepatitis B and HIV-1, your liver function tests may increase and 
symptoms caused by hepatitis may get worse if you stop TAF.   
• Because there is only a small amount of information on TAF in pregnant and breastfeeding women, 
you should not use TAF during pregnancy or if breastfeeding. 
 
Lactic acidosis (elevated lactic acid levels in the blood) and severe hepatomegaly (enlarged liver) with 
steatosis (fatty liver) that may result in liver failure, other complications, or death have been reported 
with the use of antiretroviral nucleoside analogues, such as FTC, when used alone or in combination. 
The liver complications and death have been seen more often in women on these drug regimens. Some 
nonspecific symptoms that might indicate lactic acidosis include: unexplained weight loss, stomach 
discomfort, nausea, vomiting, fatigue, cramps, muscle pain, weakness, dizziness, and shortness of 
breath.  
 
Some side effects of TAF may not need any medical attention. As your body gets used to the medicine, 
these side effects may disappear.  
 
Cobicistat (COBI) 
The following side effects have been associated with the use of COBI: 
Less likely 
• Abdominal or stomach pain 
• Bloody urine 
• Chills 
• Clay-colored stools 
• Dark urine 
• Decreased frequency or amount of urine 
• Dizziness 
• Fast heartbeat 
• Fever 
• Headache 
• Hives or welts, itching, or rash 
• Hoarseness 
• Increased thirst 
• Irritation 
• Joint pain, stiffness, or swelling 
• Loss of appetite 
• Lower back or side pain 
• Nausea and vomiting 
• Pain in the groin or genitals 
• Redness of the skin 
• Sharp back pain just below the ribs 
• Swelling of the eyelids, face, lips, hands, lower legs, or feet 
• Tightness in the chest 
• Troubled breathing or swallowing 


 
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• Unpleasant breath odor 
• Unusual tiredness or weakness 
• Vomiting of blood 
• Weight gain 
• Yellow eyes or skin 
• Dark-colored urine 
• Muscle cramps or spasms 
• Muscle pain or stiffness 
• Diarrhea 
• Discouragement 
• Feeling sad or empty 
• Irritability 
• Loss of interest or pleasure 
• Trouble concentrating 
• Trouble sleeping 
• Upper abdominal or stomach pain 
 
Some side effects of COBI may not need medical attention. As your body gets used to the medicine, 
these side effects may disappear.  
 
Elvitegravir (EVG) 
Less Likely 
The following side effects have been associated with the use of EVG: 
• Diarrhea 
• Headache 
• Nausea 
• Discouragement 
• Feeling sad or empty 
• Heartburn 
• Indigestion 
• Irritability 
• Lack of appetite 
• Loss of interest or pleasure 
• Rash 
• Stomach discomfort, upset, or pain 
• Thoughts or attempts at killing oneself 
• Trouble concentrating 
• Trouble sleeping 
• Unusual tiredness or weakness 
• Vomiting 
 
Some unwanted effects may be caused by EVG. In the event that any of these side effects do occur, they 
may require medical attention. Some of the side effects that can occur with EVG may not need medical 
attention. As your body adjusts to the medicine during treatment, these side effects may go away. Your 


 
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health care professional may also be able to tell you about ways to reduce or prevent some of these side 
effects. If any of the aforementioned side effects continue, are bothersome, or if you have any questions 
about them, check with your health care professional. 
Use of Combination Antiretroviral (ARV) Drugs 
In some people with advanced HIV-1 infection, symptoms from other infections or certain diseases may 
occur soon after starting combination ART but can also occur later.  Some of these symptoms may be 
life threatening. If you start having new symptoms, or notice that existing symptoms are getting worse 
after starting your ART, tell your health care provider right away. 
The use of potent ARV drug combinations may be associated with an abnormal placement of body fat 
and wasting. Some of the body changes include: 
• Increase in fat around the waist and stomach area 
• Increase in fat on the back of the neck 
• Thinning of the face, legs, and arms 
• Breast enlargement  
 
There is a risk of serious and/or life-threatening side effects when non-study-provided medications are 
taken with the study-provided drugs. For your safety, you must tell the study doctor or nurse about all 
medications you are taking before you start the study. It is also important that you do not start any new 
medications while on the study before discussing it with the study doctor or nurse. Also, you must tell 
the study doctor or nurse before enrolling in any other clinical trials while on this study. 
 
 
Risks of Optional Procedures 
Leukapheresis  
Likely 
• Fatigue 
 
Less Likely 
• Nausea  
• Vomiting  
• Fainting or dizziness  
• Bruising or swelling where the needles are put in  
• Low blood pressure, which can cause dizziness, lightheadedness, of fainting  
• Increased pulse rate  
• Seizures  
• Blood loss  
• Infection  
 
Rare: 
• Allergic reaction to some of the material used during the leukapheresis.  
• The procedure might have to be stopped early, before it is finished, and could result in the loss of 
as much as 1/2 pint of blood if it is not possible to complete the return of blood to the participant. 
 


 
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During the procedure, you will receive a compound called ACD-A (citrate), which prevents blood from 
clotting. Citrate is approved by the U.S. Food and Drug Administration for use in this procedure. Citrate 
leaves the body within 15-30 minutes after the procedure is complete. If you notice any symptoms while 
undergoing leukapheresis please let the nurse know immediately since the symptoms can usually be 
treated. 
 
Likely 
• Muscle cramping 
• Numbness or tingling of the lips and/or fingers 
• Chills 
• Feeling that the body is vibrating 
• Feelings of anxiety 
Rare 
• Seizures   
 
Gut Biopsy/Rectal biopsy  
Likely 
• Discomfort during the collection of tissue sample.  
• Urge to have a bowel movement  
• Cramping as the instrument is placed into the rectal area  
• Feeling of a “bloated stomach”  
Rare: 
• Pain  
• Infection  
• Bleeding or perforation (a cut or a hole) of the gastrointestinal tract (this occurs about once out 
of every 1000 procedures and may require hospitalization and surgical management) 
 
Lumbar puncture 
Less Likely 
• Headache, sometimes severe 
• Back pain, slight 
• Bruising, soreness at collection site 
• Dizziness, nausea 
• Fever 
• Numbness  
Extremely Rare 
• Paralysis 
 
There is a federal law called the Genetic Information Nondiscrimination Act (GINA). In general, this 
law makes it illegal for health insurance companies, group health plans and employers with greater than 
15 employees to discriminate against you based on your genetic information. However, it does not 
protect you against discrimination by companies that sell life insurance, disability insurance or long 
term-care insurance.  
 
 


 
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Breach of Confidentiality 
One risk of participating in this study is that confidential information about you may be accidentally 
disclosed.  We will use our best efforts to keep the information about you secure.  Please see the section 
in this consent form titled “How will you keep my information confidential?” for more information. 
 
WHAT ARE THE BENEFITS OF THIS STUDY? 
 
You may not benefit from being in this study. 
 
However, we hope that, in the future, other people might benefit from this study because this study will 
provide information that may help others with HIV-1 infection. 
 
WHAT OTHER TREATMENT OPTIONS ARE THERE? 
 
Before you decide whether or not to be in this study, your doctor will discuss the other options that are 
available to you.  Instead of being in this study, you have the choice of: 
• treatment with the anti-HIV drugs available to you locally 
• treatment with investigational drugs, if there is a study available locally for which you qualify  
• no treatment  
 
Each of these options has risks and benefits. There are several drug regimens that you and you provider 
could elect to begin. These have the prospect of controlling HIV infections but all have potential side 
effects much like those listed of the study drug. Investigational treatment options also may result in 
control of HIV infections but all involve risks, many of which are unknown. Finally, not treating your 
HIV infection avoids the risks of medications but may risk progression of the disease. 
 
Please talk to your doctor about these and other choices available to you. Your doctor will explain the 
risks and benefits of these choices. 
 
WILL IT COST ME ANYTHING TO BE IN THIS STUDY? 
 
The sponsor is providing the study drug (EVG/COBI/FTC/TAF) at no cost to you. 
You will not have any additional costs for being in this research study. 
You and/or your medical/hospital insurance provider will remain responsible for your regular medical 
care expenses. 
 
WILL I BE PAID FOR PARTICIPATING? 
 
You will be paid for being in this research study. You will need to provide your social security number 
(SSN) in order for us to pay you. You may choose to participate without being paid if you do not wish to 
provide your social security number (SSN) for this purpose.  You may also need to provide your address 
if a check will be mailed to you. Checks arrive to the address you give us within about ten business days 
of a visit. If your social security number is obtained for payment purposes only, it will not be retained 
for research purposes.    
 
You will receive payments beginning at study screening at the rate of 
 per visit. There are 10 


 
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possible visits for a total over the life of the study of 
  
 
If you complete the optional procedures, you will be paid 
 per procedure. If you complete all 3 
optional procedures, you will receive a total of 
 for the optional procedures. 
 
If you do not complete all visits, you will be paid for the visits you do complete. 
 
WHO IS FUNDING THIS STUDY? 
 
The National Institutes of Health (NIH) is funding this research study.  This means that Washington 
University is receiving payments from the NIH to support the activities that are required to conduct the 
study.  No one on the research team will receive a direct payment or increase in salary from the NIH for 
conducting this study. 
 
WHAT IF I AM INJURED AS A RESULT OF THIS STUDY? 
 
Washington University investigators and staff will try to reduce, control, and treat any complications 
from this research. If you feel you are injured because of the study, please contact the investigator at 
 and/or the Human Research Protection Office at 
.  
 
Decisions about whether payment for medical treatment for injuries relating to your participation in 
research will be made by Washington University. There is no program for compensation through the 
National Institutes of Health. If you need to seek medical care for a research-related injury, please notify 
the investigator as soon as possible.  
 
HOW WILL YOU KEEP MY INFORMATION CONFIDENTIAL? 
 
It is possible that other people such as those indicated below may become aware of your participation in 
this study and may inspect and copy records pertaining to this research.  Some of these records could 
contain information that personally identifies you.  
• Government representatives, (including the Office for Human Research Protections) to complete 
federal or state responsibilities 
• The U.S. Food and Drug Administration (FDA) 
• The National Institutes of Health (NIH) 
• The ACTG 
• Gilead Sciences, Inc., providing the study drug 
• Your primary care physician if a medical condition that needs urgent attention is discovered 
• Hospital or University representatives, to complete Hospital or University responsibilities 
• Information about your participation in this study may be documented in your health care records 
and be available to your health care providers who are not part of the research team.  
• The last four digits of your social security number may be used in hospital or University systems 
to track billing information for research procedures 
• Washington University’s Institutional Review Board (a committee that oversees the conduct of 
research involving human participants) and the Human Research Protection Office. The 
Institutional Review Board has reviewed and approved this study.  


 
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The research team will send study results to the National Institutes of Health (NIH).  Information sent to 
the National Institutes of Health (NIH) is given a code number and does not identify you for the 
purposes of conducting this study. The National Institutes of Health (NIH) will use this information to 
study the safety and effectiveness of the drug. In the future, the National Institutes of Health (NIH) may 
continue to use your health information that is collected as part of this study. For example, the National 
Institutes of Health (NIH) may combine information from this study with the results of other studies to 
re-analyze the safety and effectiveness of the study drug, to evaluate other products or therapies, to 
develop a better understanding of a disease, or to improve the design of future research studies. The 
National Institutes of Health (NIH) may also share information from the study with regulatory agencies 
in foreign countries. 
 
If you receive Medicare benefits, are injured as part of your participation in this research study and 
medical treatment relating to this injury is paid by anyone other than you or your insurance company, 
that payer will need to collect personal information about you.  This information includes your name, 
date of birth, gender, social security number, Medicare identification number and information related to 
this research study. The payer will report this information to the Centers for Medicare & Medicaid 
Services (CMS), the federal agency that oversees the Medicare program, during your participation in the 
study and for as long as the payer is required by CMS to report this information.  If you do not want to 
release your personal or treatment related information you have the right to refuse reimbursement by the 
payer for any research injury.  The payer will not use this information for any other purpose. 
 
Research monitors, auditors, the study sponsor, the Institutional Review Board, and other regulatory 
authorities will be granted directed access to your original health care record to verify the conduct of the 
clinical trial procedures and/or data. This access will be permitted to the extent permitted by the 
applicable laws and regulations without violating the confidentiality of your information. By signing this 
form you are authorizing such access. 
 
To help protect your confidentiality, we will assign the information you give us a code number.  We will 
protect your information, but there is a chance somebody might see it. 
 
• 
Electronic records - Any computer data is accessible only by passwords which are changed every 
90 days.  
• 
Blood, urine, CSF, and tissue samples – Initially labeled only with ID number, gender, date of 
birth, and date and time of collection, then barcode that has no identifying information on it. 
• 
Paper/hard copy records - Patient information is given a code number. A master list linking the 
code number and subject identity will be kept separate from the research data. Only the principal 
investigator and people helping him/her will be able to see the list.  
• 
Kept in locked, security controlled environment.  
 
If we write a report or article about this study or share the study data set with others, we will do so in 
such a way that you cannot be directly identified 
 


 
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A description of this clinical trial will be available on http://www.ClinicalTrials.gov, as required by U.S. 
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. 
 
To further protect your privacy, the investigator has obtained a Certificate of Confidentiality from the 
Department of Health and Human Services (DHHS).  This Certificate may prevent the investigator from 
being forced (for example by court subpoena) to disclose information that may identify you in any 
federal, state, or local civil, criminal, administrative, legislative, or other proceeding.  However, a 
Certificate of Confidentiality does not prohibit the investigator from disclosing information about you or 
your involvement in this research that you have agreed to disclose or make available.  For example, if 
you request in writing that information about you or your participation in the research be released to an 
insurance company, the investigator may not use the Certificate of Confidentiality to withhold this 
information.  This means that you and your family should actively protect your own privacy.  Finally, 
the investigator is not prevented from disclosing, including reporting to appropriate authorities, 
information concerning abuse, neglect or harm to others or yourself. 
 
Are there additional protections for my health information? 
Protected Health Information (PHI) is health information that identifies you. PHI is protected by federal 
law under HIPAA (the Health Insurance Portability and Accountability Act). To take part in this 
research, you must give the research team permission to use and disclose (share) your PHI for the study 
as explained in this consent form.  The research team will follow state and federal laws and may share 
your health information with the agencies and people listed under the previous section titled, “How will 
you keep my information confidential?” 
 
Once your health information is shared with someone outside of the research team, it may no longer be 
protected by HIPAA.   
 
The research team will only use and share your information as talked about in this form or as permitted or 
required by law.  When possible, the research team will make sure information cannot be linked to you 
(de-identified).  Once information is de-identified, it may be used and shared for other purposes not 
discussed in this consent form. If you have questions or concerns about your privacy and the use of your 
PHI, please contact the University’s Privacy Officer at 
.  
 
Although you will not be allowed to see the study information, you may be given access to your health 
care records by contacting your health care provider.  
 
If you decide not to sign this form, it will not affect 
• your treatment or the care given by your health provider. 
• your insurance payment or enrollment in any health plans.   
• any benefits to which you are entitled. 
However, it will not be possible for you to take part in the study. 
 
If you sign this form: 
• You authorize the use of your PHI for this research 
• This authorization does not expire. 


 
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• You may later change your mind and not let the research team use or share your information 
(you may revoke your authorization).  
• To revoke your authorization, complete the withdrawal letter, found in the Participant section 
of the Human Research Protection Office website at 
http://hrpo.wustl.edu/participants//withdrawing-from-a-study/ or you may request that the 
investigator send you a copy of the letter.    
 
 
 
o If you revoke your authorization: 
 The research team may only use and share information already collected for 
the study. 
 Your information may still be used and shared as necessary to maintain the 
integrity of the research, for example, to account for a participant’s 
withdrawal from the research study or for safety reasons. 
 You will not be allowed to continue to participate in the study. 
 
Can we contact you by email? 
We would like to contact you by email for the purposes listed below.  Some of these emails may contain 
health information that identifies you. 
• Appointment scheduling and confirming 
• Questions you may have 
• Lab results if you desire 
 
Only the research team will have access to your e-mail communications.  We will only communicate by 
email to send you the information listed above.  If you have any questions or need to contact us for an 
urgent or emergent situation, please contact the research team member identified at the top of this 
document. 
 
You should be aware that there are risks associated with sending your health information via e-mail.   
• There is always a risk that the message could be intercepted or sent to the wrong e-mail 
address.  To avoid sending messages to the wrong e-mail address, the first e-mail we send 
you will be a test message to ensure we have the correct e-mail address. 
• When using any computer you should be careful to protect your username and password.  
Make sure you log-out before getting up from the computer.   
• If you share a home computer with other family members, and do not want them to know you 
are participating in this study make sure you provide an e-mail address that only you can 
access.  
• Your employer will have access to any e-mail communications sent or received on any 
electronic devices for work or through a work server. 
 
Do you agree to allow us to send you protected health information via e-mail?   
 
_____ Yes  
_____ No 
Initials 
Initials 
 
 


 
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IS BEING IN THIS STUDY VOLUNTARY? 
 
Taking part in this research study is completely voluntary.  You may choose not to take part at all.  If 
you decide to be in this study, you may stop participating at any time. Any data that was collected as 
part of your participation in the study will remain as part of the study records and cannot be removed.   
 
If you decide not to be in this study, or if you stop participating at any time, you won’t be penalized or 
lose any benefits for which you otherwise qualify.   
 
What if I decide to withdraw from the study? 
You may withdraw by telling the study team you are no longer interested in participating in the study or 
you may send in a withdrawal letter. A sample withdrawal letter can be found at 
http://hrpo.wustl.edu/participants/ under Withdrawing from a Research Study. 
 
If you decide to leave the study early, or must stop taking ART before the study is over, then the study 
staff will ask you to return to the clinic for a final visit. 
 
Will I receive new information about the study while participating? 
If we obtain any new information during this study that might affect your willingness to continue 
participating in the study, we’ll promptly provide you with that information. 
 
Can someone else end my participation in this study? 
Under certain circumstances, the investigator or the study sponsor might decide to end your participation 
in this research study earlier than planned. This might happen for no reason or because  
• You never started ART (study-provided or non-study-provided drugs) or started ART later than 48 
hours after joining the study. 
• An HIV-1 test shows that you are not infected with HIV or you have had HIV infection for a longer 
period of time than expected or your laboratory tests from entry show that you do not qualify for the 
study. 
• You miss 3 study visits in a row.  
• Your viral loads show that the HIV medications you are taking are no longer working well for you; 
this is known as having VF. 
• Your study doctor believes that remaining on the study is no longer what is best for you. 
• You are unable to follow the requirements of the study or at the recommendation of the IRB/EC, 
NIAID, OHRP, other government agencies as part of their duties, or industry supporter.    
• A Study Monitoring Committee (SMC), an outside group of experts that monitors the study, 
recommends that the study be stopped early or canceled. 
 
The study doctor may also need to take you off the study-provided drugs without your permission if: 
 
• Continuing the study-provided drugs may be harmful to you, for example, if the study drugs are 
making you sick. 
• You need a treatment that you may not take while on the study-provided drugs.  
• You become pregnant and/or start breastfeeding. 
 


 
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Page 21 of 22 
 
WHAT IF I HAVE QUESTIONS? 
 
We encourage you to ask questions.  If you have any questions about the research study itself, please 
contact: Rachel Presti, MD at Telephone: 
. If you experience a research-related injury, 
please contact: Rachel Presti, MD at 
.  
 
If you have questions, concerns, or complaints about your rights as a research participant, please contact 
the
  
   General information about being a research 
participant can be found on the Human Research Protection Office web site, http://hrpo.wustl.edu.  To 
offer input about your experiences as a research participant or to speak to someone other than the 
research staff, call the Human Research Protection Office at the number above. 
 
 
 
This consent form is not a contract. It is a written explanation of what will happen during the study if 
you decide to participate. You are not waiving any legal rights by agreeing to participate in this study. 
As a participant you have rights and responsibilities as described in this document and including: 
• To be given enough time before signing below to weigh the risks and potential benefits and 
decide if you want to participate without any pressure from the research team or others. 
• To understand all of the information included in the document, have your questions answered, 
and receive an explanation of anything you do not understand. 
• To follow the procedures described in this document and the instructions of the research team to 
the best of your ability unless you choose to stop your participation in the research study. 
• To give the research team accurate and complete information. 
• To tell the research team promptly about any problems you have related to your participation, or 
if you are unable to continue and wish to stop participating in the research study. 
 
Your signature indicates that this research study has been explained to you, that your questions have 
been answered, and that you agree to take part in this study.  You will receive a signed and dated copy 
of this form. 
 
 
Do not sign this form if today’s date is after EXPIRATION DATE: 06/08/17. 
 
 
__________________________________________ 
_______________________________ 
(Signature of Participant) 
 
 
 
 
(Date) 
 
 
____________________________________________ 
(Participant's name – printed) 
 
 


 
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Statement of Person Who Obtained Consent 
 
The information in this document has been discussed with the participant or, where appropriate, with the 
participant’s legally authorized representative.  The participant has indicated that he or she understands 
the risks, benefits, and procedures involved with participation in this research study. 
 
 
__________________________________________ 
_______________________________ 
(Signature of Person who Obtained Consent) 
 
(Date) 
 
 
___________________________________________ 
(Name of Person who Obtained Consent - printed) 
 
 
 

SAP_002.pdf: 
Approvals 


 
 
 
 
 
This is ACTG A5354 SAP Version 3.0 with names of authors, names of publication writing 
team members and analysis timeline redacted. 
 
 
 
ACTG 5354 
Primary Statistical Analysis Plan 
Version 3.0 
 
Effect of Antiretroviral Treatment Initiated During Acute 
HIV-1 Infection on Measures of HIV-1 Persistence and on 
HIV-1-Specific Immune Responses 
Protocol Version 2.0; LOA#1 and LOA#2 
ClinicalTrials.gov Identifier: NCT02859558 
 
September 14, 2021 
 
Created by: 
Summer Zheng, Justin Ritz, Joseph Puleo 
Statistical and Data Analysis Center for the AIDS Clinical Trials Group 
Harvard TH Chan School of Public Health 
 


ACTG A5354 
Primary Statistical Analysis Plan 
 
Page 1 of 20 
 
 
Table of Contents 
TABLE OF CONTENTS ................................................................................................................... 1 
VERSION HISTORY ........................................................................................................................ 2 
1 
INTRODUCTION ........................................................................................................................ 3 
2 
STUDY OVERVIEW ................................................................................................................... 4 
3 
ANALYSIS REPORTS ............................................................................................................... 6 
4 
GENERAL ANALYSIS CONSIDERATIONS ............................................................................. 7 
5 
ACCRUAL ............................................................................................................................... 10 
6 
BASELINE CHARACTERISTICS ........................................................................................... 10 
7 
FIEBIG STAGE ........................................................................................................................ 11 
8 
ACUTE HIV-1 INFECTION (AHI) TESTING ............................................................................ 12 
9 
STUDY STATUS AND LOSS TO FOLLOW-UP ..................................................................... 12 
10 PREGNANCY OUTCOMES .................................................................................................... 12 
11 ANTIRETROVIRAL THERAPY STATUS ................................................................................ 13 
12 ADVERSE EVENTS ................................................................................................................ 13 
13 CD4/CD8 CELL COUNTS ....................................................................................................... 14 
14 STANDARD HIV-1 RNA AND VIROLOGIC FAILURE ........................................................... 14 
15 PROCEDURE SUMMARY (INTERIM) .................................................................................... 15 
16 DATA COMPLETENESS SUMMARY (INTERIM) .................................................................. 15 
17 PRIMARY OUTCOME MEASURE .......................................................................................... 16 
18 SECONDARY OUTCOME MEASURES ................................................................................. 17 
19 OTHER OUTCOME MEASURES ............................................................................................ 19 
20 ASSOCIATED DOCUMENTS ................................................................................................. 20 
 
 
 


ACTG A5354 
Primary Statistical Analysis Plan 
 
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Version History 
 
Version 
Changes Made 
Date Finalized 
1.0 
Original Version 
11MAY2017 
2.0 
Updates for protocol version 2.0 and latest CBAR SAP template 
05MAY2020 
3.0 
Updates for LOAs to protocol version 2.0  
14SEP2021 
 
 
 


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Primary Statistical Analysis Plan 
 
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1 
Introduction 
1.1 
Purpose 
This Primary Statistical Analysis Plan (SAP) describes the primary and secondary outcome 
measures and additional outcome measures of the ACTG A5354 study that will be included in the 
primary manuscript, and which address, at a minimum, the major primary and secondary objectives 
of the study. The Primary SAP 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 among 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 
analysis report. It also describes the results for the primary and secondary outcome measures that 
will be posted on ClinicalTrials.gov.   
A subset of these analyses (as described herein) will form the basis of reports provided to the Study 
Monitoring Committee (SMC) while the study is ongoing.  This analysis plan therefore includes the 
key analyses that might lead to modification or termination of the study, and hence form the core 
of any presentation or publication used to disseminate the primary conclusions of the study.  
However, it is recognized that this analysis plan may be modified by the study team as new 
information becomes available outside of the study, or to reflect recommendations made by the 
SMC or changes in the study design.  In addition, some analyses, tables, or figures may be omitted 
at interim analyses if there are insufficient data to warrant analysis or at the request of the SMC. 
Analyses for the Primary Analysis Report will be finalized once the last participant has completed 
the Week 72 study visit on Step 1, all queries have been resolved, and the standard study 
database procedures have been completed.  
Outlines of analyses for other objectives, including Step 2 follow up, and outcome measures not 
included in the Primary SAP will be provided in a separate SAP. 
1.2 
Version History 
Version 2.0 of the A5354 SAP was created primarily in order to reflect changes made to the study 
in protocol v2.0.  
One major change to the study in protocol v2.0 was an addition of 144 weeks of additional follow-
up, incorporated as Step 2 of the study.  Analyses for Step 2 will be encapsulated in a separate 
analysis plan.  
Protocol v2.0 also states that the cell-associated DNA testing performed for the primary outcome 
measure at week 48 on Step 1 will be done separately by gag- and integrase-assays. Therefore, 
the analyses outlined for the primary outcome measure have been updated to reflect the pair of 
results that will be generated. 
Version 3.0 of the A5354 SAP was updated to reflect changes to the study via LOA #1 and #2 to 
protocol version 2.0. Several secondary objectives and corresponding outcome measures were 
redesignated as exploratory objectives and ‘other’ outcome measures. 


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Primary Statistical Analysis Plan 
 
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2 
Study Overview 
2.1 
Study Design 
A5354 is a phase II, prospective, open-label 2-step study to measure the effects of early 
antiretroviral therapy (ART) on the establishment of HIV-1 reservoir and HIV-1-specific immunity. 
Treatment-naïve participants with acute HIV-1 infection (AHI) will have an enrollment visit that will 
include the immediate initiation of ART. The primary outcome measure is cell-associated HIV-1 
DNA (CAHD) in 5 million blood-derived CD4+ T-cells assayed by quantitative PCR (qPCR) at 
week 48 on Step 1.  
A subset of participants who have completed week 48 on Step 1 will be consented for 
leukapheresis or large volume blood collection, cerebrospinal fluid collection via lumbar puncture, 
and gut biopsy via flexible sigmoidoscopy. Approximately 25 participants are estimated to have 
each optional procedure. Participants may consent to one or more of these optional procedures, 
which will be performed at any time on Step 1 from week 60 to week 72 in willing participants.  
Willing participants who have completed Step 1 follow-up without meeting any criteria for 
permanent study discontinuation (per section 9.2) will be encouraged to continue on Step 2 and 
complete study evaluations through 144 weeks of Step 2 follow-up. Participants who had 
previously completed the study at week 72 per protocol version 1.0 will be allowed to re-enroll in 
protocol version 2.0 if they meet Step 2 eligibility criteria. The “re-enrolled” participants will be 
placed in their original Fiebig group that they were initially enrolled under protocol version 1.0 
The Fiebig stage-classification system will be used to characterize the progression from HIV-1 
exposure to HIV-1 seroconversion at the time of ART initiation. Plasma and serum samples will 
be collected at the time of ART initiation and the results of the Fiebig stage at ART initiation will 
be available to sites within 12 weeks. In this study, the Fiebig I-V stages of interest will be 
simplified into three study groups (based on HIV-1 antibody diagnostic profile at the time of ART 
initiation) as described below.  
Group 1: 
Fiebig I/II (non-reactive HIV-1 antibody)  
Group 2: 
Fiebig III/IV (reactive HIV-1 antibody and negative or indeterminate results on the 
Western blot or Geenius HIV-1/HIV-2)  
Group 3: 
Fiebig V (reactive HIV-1 antibody and positive Western blot or Geenius HIV-
1/HIV-2 without p31 band)  
It is possible that a small number of participants will be determined to be in Fiebig VI (positive 
Western blot or Geenius HIV-1/HIV-2 with p31 band) based on analysis of the entry samples 
even though these participants are not specifically targeted for enrollment in this study. 
Participants who are determined to be in Fiebig VI will be followed on the study for no more than 
24 weeks on Step 1, allowing ample time for them to pursue alternative sources for ART. 
Confirmed Fiebig VI participants will be replaced.  


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Primary Statistical Analysis Plan 
 
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The Clinical Management Committee of the A5354 protocol team will review the Fiebig staging 
and ensure that these results are communicated to the site, as described in the study’s Manual of 
Procedures. 
2.2 
Duration 
Up to 216 weeks (72 weeks on Step 1 and 144 weeks on Step 2). 
2.3 
Sample Size 
A total of 196 participants. Each study group had a target enrollment of 50 participants under 
protocol version 1.0. From these study groups, up to 25 eligible participants will be asked to 
consent to each optional procedure. 
2.4 
Population 
Men and women 18 years and older with AHI. Pregnant and breastfeeding women are permitted 
to enroll in the study. 
2.5 
Regimen 
The antiretroviral (ARV) regimen provided through the study is the single tablet regimen 
elvitegravir/cobicistat/emtricitabine/tenofovir alafenamide (EVG/COBI/FTC/TAF) or 
bictegravir/emtricitabine/tenofovir alafenamide (BIC/FTC/TAF). Other non-study-provided ARV 
regimens will be allowed for participants who are pregnant, breastfeeding, or unable/unwilling to 
take EVG/COBI/FTC/TAF or BIC/FTC/TAF, or for participants whose local health care/primary 
care provider prefers starting a different initial ARV regimen. 
2.6 
Hypotheses 
Timing of antiretroviral therapy (ART) during different stages of acute HIV-1 infection (AHI) will be 
predictive of the magnitude and characteristics of HIV-1 reservoirs, and the quantity and quality of 
HIV-1-specific immune responses at week 48 on Step 1.    
- ART initiation prior to HIV-1 antibody detection will be associated with limited or no 
detectable proviral DNA or HIV-1-specific immune responses at week 48 on Step 1. 
- ART initiation in later AHI stages will be associated with larger HIV-1 reservoir 
establishment and quantitatively and qualitatively different HIV-1-specific immune 
responses at week 48 on Step 1. 
2.7 
Study Objectives 
2.7.1 
Primary Objectives 
To compare the amount of cell-associated HIV-1 DNA (CAHD) in 5 million blood-derived CD4+ T-
cells (assayed by quantitative PCR [qPCR]) at week 48 on Step 1 among participants who 
initiated ART in Fiebig I/II versus Fiebig III/IV versus Fiebig V and had sustained suppression of 
plasma HIV-1 RNA 
2.7.2 
Secondary Objectives 
1. To evaluate HIV-1-specific CD4+ and CD8+ T-cells by flow cytometry while HIV-1 RNA is 


ACTG A5354 
Primary Statistical Analysis Plan 
 
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suppressed on ART: 
a. magnitude and distribution of CD4+ and CD8+ T-cells responses to nef, gag, pol and 
env 
b. quality of T-cell responses (i.e. frequency and type of polyfunctional responses) 
 
2. To assess cell-associated HIV-1 DNA in participants prior to ART initiation. 
3. To establish a group of well-characterized, adults living with HIV who initiated ART during 
AHI that can serve as a source population for future ACTG studies, including those 
designed to test novel interventions to achieve HIV remission. 
2.8 
Overview of Sample Size Considerations 
See protocol section 10.4 for details on the sample size considerations. 
2.9 
Overview of Formal Interim Monitoring 
The study will be reviewed by a Study Monitoring Committee (SMC) according to ACTG standard 
operating procedures. The SMC will review accrual, baseline characteristics (including baseline 
laboratory values), Fiebig stage at ART initiation, AE summaries, CD4+ T-cell counts and HIV-1 
RNA levels/suppression over time, study and ART discontinuations (and reasons), and 
completeness of follow-up and sample availability. The SMC will convene, at a minimum, 6 
months after the first participant is enrolled or after 25 participants are enrolled, whichever is 
earlier and approximately annually thereafter or at the request of the SMC. 
3 
ANALYSIS REPORTS 
3.1 Interim Analysis Reports 
As outlined in the A5354 Study Progress, Data, and Safety Monitoring Plan (SPDSMP), an 
analysis report will be prepared and distributed for each SMC review. The report will be 
distributed to the SMC, DAIDS Clinical Representative, and the ACTG SDAC Coordinating 
Statistician for the SMC.  The report will include analyses from the following sections of this 
analysis plan broken out by study group: 
1. Accrual 
2. Baseline characteristics 
3. Fiebig stage summary (not included after accrual has completed) 
4. Acute HIV-1 infection testing summary (not included after accrual has completed) 
5. Study status and loss to follow-up 
6. Antiretroviral treatment status 
7. Adverse event summary 
8. Pregnancy outcomes (if any) 
9. CD4+ cell counts over time 
10. Standard HIV-1 RNA copies/mL over time  
11. Virologic failures 
12. Summary of availability of results for primary outcome measure (not included after 
primary analysis is completed)  
13. Summary of optional procedures performed and completed 


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Primary Statistical Analysis Plan 
 
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3.2 Primary Analysis Report 
Unless otherwise noted, the primary analysis report will include all sections in this analysis 
plan.  
Section 5-8 have been summarized in a separate analysis report titled “Analysis report 
evaluating criteria for diagnosing acute HIV infection” (dated July 23, 2020). Unless there are 
additional data, analyses in these sections will not be included in the primary analysis report.  
3.3 Lists of Data in Reports 
Lists of data about individual study participants may be useful for interpreting the results of 
the study and so some lists are described below.  To protect confidentiality, the content of 
these lists will be limited and for primary analyses will not include dates, participant identifier 
numbers or other combinations of information that might identify an individual participant.      
4 
GENERAL ANALYSIS CONSIDERATIONS 
4.1 Definition of “study entry”, “baseline”, and “study group” 
“Study entry” is defined as the study registration/randomization date. For the purposes of 
statistical analyses, study week 0 will include evaluations up to and including the date of 
study entry and, unless otherwise defined, baseline will be the last evaluation on or before 
the date of study entry.  
The term ‘study group’ is used throughout this analysis plan to differentiate participants 
entering the study during Fiebig stages I-II (Group 1), stages III-IV (Group 2) and stage V 
(Group 3). At screening, a participant’s study group is estimated based on the available 
laboratory test results at the site.  The estimated study group will be confirmed/rejected by 
centralized testing of samples taken at the entry visit. For interim analyses, participants who 
have yet to have the centralized Fiebig Stage result will be placed in a ‘Pending’ group.  Once 
a participant’s centralized test result is available, they will then be grouped by these results. It 
is possible that a participant, who is estimated to be in one group at screening, will be found 
to be in a different group when the centralized results become available. At the primary 
analysis, it is intended that all participants will be grouped according to the results of the 
centralized testing.  
Generally, tables will present results for the overall population and by study group. Select 
tables may also be presented by geographic region (domestic vs. international).  
4.2 Period of Follow-up 
Analyses in this document address the period of Step 1 follow-up defined by the protocol (up 
to 72 weeks following study entry). A separate analysis plan will describe the analyses for Step 
2 follow-up (an additional 144 weeks following the completion of Step 1) as well as exploratory 
objectives.   


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Primary Statistical Analysis Plan 
 
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4.3 Analysis Populations 
All participants enrolled to the study will be included in accrual and centralize Fiebig result 
summaries.  
Participants found to be HIV negative after enrollment will not be included in any summaries 
except those stated above. Participants found to be in Fiebig Stage VI will have baseline and 
select follow-up data summarized from the period of time prior to going off study (Week 24). 
Analysis of the primary outcome measure will be restricted to study groups 1-3 (as determined 
by centralized testing), and only for participants who maintain HIV-1 RNA <50 copies/mL at 
week 48 with no ART interruption of ≥7 consecutive days and have available CAHD results 
from week 48 or week 49. Sensitivity analyses will include participants with extended periods 
of ART interruption (≥7 consecutive days) that maintained HIV-1 RNA <50 copies/mL at week 
48. 
4.4 Visit Schedule and Definition of Week for Analysis Purposes 
The Step 1 visit schedule for key study outcomes is shown in Table 1 below.  The protocol 
requires evaluations to be scheduled at week 1 (±3 days), week 4 (±7 days), week 12, 24 and 
36 (±14 days), week 48 (-14 days, +3 days), *week 49 (-3 days, +14 days), and weeks 60 
and 72 (±42 days).  
*NOTE: The week 49 visit is optional, in the event that blood volumes were not sufficient at 
the week 48 visit. 
Telephone evaluations will occur at week 2 (±3 days), week 8 (±7 days) and at weeks 60 and 
72 the day following performance of the gut biopsy and/or lumbar puncture optional 
procedures.  
For the purposes of analysis, visit windows will be formed around each study visit using the 
midpoints between adjacent weeks as cutoffs, and potentially including assessments 
collected outside the recommended visit windows described above.  If there are multiple 
evaluations within the analysis window for a given visit, the evaluation closest to the 
scheduled study week will be used, and the earlier measurement will be used if there are two 
measurements that are equally distant from the scheduled week. 
Table 1 on the next page details the analysis windows for the data collected on Step 1. 
 
 


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Primary Statistical Analysis Plan 
 
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Table 1: Study Visit Schedule and Analysis Windows for Step 1 
Evaluation 
Entry 
Post-Entry Evaluations (Weeks) 
0 
1 
4 
12 
24 
36 
48 
49* 
60 
72 
Analysis window 
1-14 
days 
15-56 
days 
57-126 
days 
127-210 
days 
211-294 
days 
295-378 days 
379-462 
days 
463-546 
days 
Fiebig Staging 
X 
  
  
  
  
  
  
  
  
  
Clinical Assessment 
X 
X 
X 
X 
X 
X 
X 
  
X 
X 
Complete Physical Exam 
X 
  
  
  
  
  
  
  
  
  
Targeted Physical Exam 
  
X 
X 
X 
X 
X 
X 
X 
X 
X 
Height 
X 
  
  
  
  
  
  
  
  
  
Weight 
X 
X 
X 
X 
X 
  
X 
X 
X 
X 
Hematology, Chemistries, LFTs 
X 
  
X 
X 
X 
  
X 
  
X 
X 
CD4+/CD8+ T-cells 
X 
  
  
X 
X 
  
X 
  
X 
X 
PBMC and Plasma Storage  
X 
  
X 
X 
X 
  
X 
X 
X 
X 
Plasma HIV-1 RNA 
X 
  
X 
X 
X 
X 
X 
  
X 
X 
Total HIV-1 DNA by qPCR 
X 
  
  
  
  
  
X 
X 
  
  
Adherence Assessment 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Leukapheresis (optional) 
X  
  
  
  
  
  
  
  
X 
Large Volume Blood Collection 
(optional) 
X 
  
  
  
  
  
  
  
X 
Gut Biopsy (optional) 
  
  
  
  
  
  
  
 
X 
Lumbar Puncture (optional) 
  
  
  
  
  
  
  
  
X 
  *NOTE: The week 49 visit is optional, in the event that blood volumes were not sufficient at the week 48 visit. 
 


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Primary Statistical Analysis Plan 
 
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4.5 Validation of Programs 
All programs used to create datasets used for analyses detailed in this SAP will be validated 
following the CBAR SOP, PROG.10083, for both interim analyses for SMC review and for the 
primary analysis.  Validation of analysis programs following CBAR SOP, PROG.10083, will 
be undertaken for analyses addressing the study’s primary objective and key secondary 
objectives; these analyses are indicated in the relevant sections below.   
Furthermore, per CBAR SOPs (PROG. 10083), analyses and datasets contributing to 
the primary objective will be independently programmed (“double coded”). This 
includes all analyses, outcome measures and covariates detailed in Section 17 of this 
document. 
5 
ACCRUAL 
Table: Number enrolled by study group showing, if applicable, number with eligibility violations 
and exclusions from analysis. 
List (if applicable): Description of violations of eligibility criteria, and details of exclusions from 
analyses (including participants who are HIV Negative and Fiebig VI).  
Tables: Number (%) enrolled by month/year of enrollment: cross-tabulation by study group.  
Dates of first and last enrollments will be provided in a footnote to the table. 
Table: Number (%) enrolled by country/site: cross-tabulation by study group. 
6 
BASELINE CHARACTERISTICS 
Tables: Showing following variables: 
Demographic and enrollment information: 
a. Sex: number (%). 
b. Gender identity: number (%) 
c. 
Participant reported race and ethnicity: number (%) by category used in eligibility 
screening. 
d. Age on the day of study entry (years): N, median and 25th and 75th percentiles, min, 
max; number (%) by age group (18-29, 30-39, 40-49, 50+; years, rounded down).  
e. IV drug use: number (%) by category (never used, previously used, current user). 
f. 
Self-reported risk of HIV exposure: number (%) by category (Homosexual contact, 
heterosexual contact, injectable drug use, unknown/not reported) 
Health status information: 
a. HIV-1 RNA (copies/ml): N, number (%) by category (<40, 40-<1,000; 1,000-<10,000; 
10,000-<100,000; 100,000-<1,000,000; 1,000,000-<10,000,000; ≥10,000,000)  
b. HIV-1 RNA (log10 copies/ml): N, mean, standard deviation, median and 25th and 75th 
percentiles, min, max 
c. 
CD4+, CD8+ cell count (cells/mm3): N, mean, standard deviation, median and 25th 
and 75th percentiles, min, max; number (%) by category (<50, 50-199, 200-349, 350-
499, ≥500.)  


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Primary Statistical Analysis Plan 
 
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d. CD4/CD8 ratio: N, mean, standard deviation, median and 25th and 75th percentiles, 
min, max 
e. BMI (kg/m2): N, mean, standard deviation, median and 25th and 75th percentiles, min, 
max; number (%) by category (underweight [<18.5]; normal [18.5-<25], overweight [25-
<30]; obese [≥30]) 
f. 
HIV symptoms at AHI identification (symptomatic; asymptomatic): N, number (%) 
g. Hospitalization status at AHI identification (hospitalized; not hospitalized): N, number 
(%) 
h. Alanine Aminotransferase and Aspartate Aminotransferase (U/L): N, mean, standard 
deviation, median and 25th and 75th percentiles, min, max; 
i. 
Hematocrit (%): N, mean, standard deviation, median and 25th and 75th percentiles, 
min, max 
j. 
Hemoglobin (g/dL): N, mean, standard deviation, median and 25th and 75th 
percentiles, min, max 
k. 
Platelets (cells/mm³): N, mean, standard deviation, median and 25th and 75th 
percentiles, min, max 
l. 
Leukocytes (cells/mm³): N, mean, standard deviation, median and 25th and 75th 
percentiles, min, max 
m. Creatinine clearance (mL/min): N, mean, standard deviation, median and 25th and 
75th percentiles, min, max 
 
For Females: 
n. Pregnancy test result (positive, negative, not of reproductive potential): N, number (%) 
o. Breast-feeding status (no, yes): N, number (%) 
 
For individuals with genotype results reported from SOC: 
p. HIV subtype (B, C, CRF#, etc.): N, number (%) 
q. HIV genotype drug resistance interpretations (Susceptible, Intermediate, Resistant, 
Not Reported) for each of the drugs reported: N, number (%) 
 
NOTE: Due to the variety of genotype results reported, interpretations for a given drug 
may not be available for all participants 
7 
FIEBIG STAGE 
Tables showing the following: 
a. Cross tabulation of the study group estimated at entry, and that determined by 
centralized testing: number (%) 
b. Time (weeks) between study entry and Fiebig stage results (latest assay date) 
determined by centralized testing: N, mean, standard deviation, median and 25th and 
75th percentiles 
c. Time (weeks) between screening and study entry: N, mean, standard deviation, 
median and 25th and 75th percentiles 


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Primary Statistical Analysis Plan 
 
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d. Fiebig stage determined by centralized testing: number (%) overall and by country  
e. Listing: Participants found to be HIV negative after enrollment, showing estimated 
Fiebig group at screening, screening assay timing/results, centralized assay 
timing/results, components and duration of ART regimen taken (if applicable), HIV-1 
RNA assay results, site, and duration on study 
8 
ACUTE HIV-1 INFECTION (AHI) TESTING  
This section has been defined in a separate statistical analysis plan 
(A5354_AHIDiag_Statistical_Analysis_Plan_v1.0_6MAR2020, dated Mar. 6, 2020). 
9 
STUDY STATUS AND LOSS TO FOLLOW-UP 
CONSORT-style diagrams will be developed for the primary analysis summarizing key 
components of the study follow-up of the study population. 
9.1 Study Status and Completeness of Follow-up of Participants 
Table: Number (%) for the following categories: 
i. 
‘Completed Step 1 as defined by the protocol’ or ‘On study’ (for interim analyses).   
ii. 
“Off study” due to death. 
iii. 
“Off study” prior to end of Step 1 follow-up (or, at interim analyses, prior to data retrieval 
date) for reasons other than death (with subcategories showing reason and whether 
or not prior to week 48 on Step 1).  
Listing: Showing all premature discontinuations with centralized Fiebig Stage result, site, 
timing and reason of premature discontinuation, week of last clinic visit, ARV regimen taken, 
and whether a sample was collected at the week 48/49 visit. 
9.2 Duration of Follow-up Achieved 
Table: Time (weeks) from study entry to last visit reported: median, 25th and 75th percentiles, 
minimum, and maximum.   
NOTE: At the primary analysis, all analyses from here onwards will be undertaken after 
any exclusions from analyses. Participants who are determined to be Fiebig Stage VI by 
centralized testing will be followed and presented until they are taken off study at week 
24. 
10 PREGNANCY OUTCOMES 
Listing: Site, study week of pregnancy outcome, pregnancy outcome, estimated week of 
conception, gestational age at pregnancy outcome, ART taken from study entry/pregnancy 
onset to time of pregnancy outcome (showing also week of changes in ART, if any). 
Listing (if available): Other pregnancy outcome information collected. 


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Primary Statistical Analysis Plan 
 
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11 ANTIRETROVIRAL THERAPY STATUS  
Table: summarizing the ART regimen initiated at entry: number (%) [may be included in 
baseline table] 
Table: summarizing number (%) of participants who have stopped ART treatment (No holds ≥7 
days; Hold ≥7 consecutive days), reason(s) for stopping, and whether the participant 
permanently discontinued or temporarily interrupted ART prior to, at, or after week 48.  
Table: summarizing the reasons (if any) for participants that modified their ARV regimen, along 
with the timing and reason for the change. 
NOTE: Participants who interrupt ART for ≥7 consecutive days will be considered for 
withdrawal from the study. If the ART interruption occurs prior to study week 24 on Step 1 and 
the participant has not previously demonstrated an HIV-1 RNA <50 copies/mL (prior to the hold 
lasting ≥7 consecutive days), then the participant will be withdrawn from the study and undergo 
the premature study discontinuation evaluation. 
12 ADVERSE EVENTS 
The protocol requires grading of events according 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.  
The protocol makes the following reporting requirements for signs and symptoms:  
“At Step 1 entry, signs and symptoms of all grades that occurred within 30 days prior to 
entry must be recorded as medical history.  Post-entry Grade ≥3 signs and symptoms and 
all signs and symptoms that led to a change in ART, regardless of grade” 
The protocol makes the following reporting requirements for laboratory test abnormalities:  
“At Step 1 entry, record all protocol-required laboratory values (performed by local 
laboratories) with exception of the urinalysis, regardless of grade. For post-entry 
assessments, record all laboratory values for creatinine, CrCl, AST (SGOT), and ALT 
(SGPT) regardless of grade.  Post-entry Grade ≥ 2 laboratory findings and all laboratory 
findings that led to a change in ART, regardless of grade” 
NOTE: Creatinine clearance should be graded using the categorical mL/min values from 
the DAIDS 2.1 toxicity grading tables, which begins with values below 90 mL/min. The 
percent change criteria will not apply to A5354. In Step 2, only creatinine clearance greater 
than Grade 2 should be reported. 
The protocol makes the following reporting requirements for diagnoses:  
“At Step 1 entry, all diagnoses that are described in protocol section 6.3.4 (Acute HIV-1, 
bone fractures, coronary heart disease, cancer, diabetes, tuberculosis, chronic hepatitis B 
or C, renal disease) must be recorded as medical history.  Post-entry, record all targeted 
diagnoses (see list on the A5354 PSWP) and diagnoses that led to a change in ART. 


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Primary Statistical Analysis Plan 
 
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NOTE: Uterine pregnancy does not require reporting as an AE (unless other SAE criteria 
are met) but must still be recorded in the eCRFs.” 
Additionally, all AEs meeting the SAE definition or EAE reporting requirements, or led to a 
change in study treatment, must be reported. 
For the purpose of ongoing safety monitoring occurring within A5354, the following data 
summaries will be provided at each interim analysis, separately for Step 1 and Step 2: 
Table: summarizing number (%) of participants and the adverse events reported in the 
database, by MedDRA SOC, PT, grade and study group. 
Table: summarizing number (%) of participants and the serious adverse events reported in the 
database, by MedDRA SOC, PT, grade and study group. 
Note: For participants enrolled to Step 2, AEs on Step 1 will be summarized up to last study 
visit on Step 1 in the primary analysis report of Step 1. Any AEs reported after the last visit on 
Step 1 prior to entry to Step 2 will be summarized in the analysis for Step 2 long-term follow-
up. 
 
13 CD4/CD8 CELL COUNTS 
Summaries at each measurement week: 
Table: CD4+, CD8+ cell count (cells/mm3): N, mean, standard deviation, median and 25th and 
75th percentiles, min, max;  
Table: Change from baseline (calculated as FU-BL) in CD4+, CD8+ cell count (cells/mm3): N, 
mean, standard deviation, median and 25th and 75th percentiles, min, max 
Table: CD4/CD8 ratio: N, mean, standard deviation, median and 25th and 75th percentiles, 
min, max. 
Table: Fold change from baseline (calculated as FU/BL) in CD4/CD8 ratio: N, mean, standard 
deviation, median and 25th and 75th percentiles, min, max 
14 STANDARD HIV-1 RNA AND VIROLOGIC FAILURE 
Summaries of HIV-1 RNA at each measurement week: 
Table: HIV-1 RNA viral load (log10 copies/mL): N, mean, standard deviation, median and 25th 
and 75th percentiles, min, max; number (%) by category (<50, ≥50; and separately for <200 
copies/mL and ≥200 copies/mL) 
Table: 95% confidence interval based on exact binomial distribution on proportion of HIV-1 
RNA < 50 or 200 copies/mL at each study week. 
Plot: Proportion of participants with HIV-1 RNA <50 or 200 copies/mL by study week, overall 
and by Fiebig group 
Summaries/Listing of confirmed virologic failure: 


ACTG A5354 
Primary Statistical Analysis Plan 
 
Page 15 of 20 
 
 
Table: Number of participants with confirmed virologic failure (defined as two consecutive HIV-
1 RNA >200 copies/mL at Step 1 week 24 or later or at any time after achieving HIV-1 RNA 
<50 copies/mL); 
Listing: (For participants with confirmed virologic failure) Initial failure week and HIV-1 RNA 
copies/mL, confirmed failure week and HIV-1 RNA copies/mL, ART regimen at the time of 
initial/confirmed failure, duration of ART regimen at the time of failure, Fiebig stage/study group 
15 PROCEDURE SUMMARY (INTERIM) 
Table summarizing: 
a. Number (%) of participants who consented and successfully completed each optional 
procedure 
b. Number (%) of participants consenting to and receiving multiple procedures 
c. Summary of week the procedure(s) was consented to and week the procedure was 
performed: N, median, 25th and 75th percentiles, min, max 
16 DATA COMPLETENESS SUMMARY (INTERIM) 
To be generated and provided by Frontier Sciences, the Data Management Center.  
Will contain summaries of completeness of collection for following study data: 
a. Serum creatinine, creatinine clearance 
b. AST, ALT 
c. CD4+/CD8+ 
d. Plasma HIV-1 RNA 
Specimens for: 
e. Fiebig Staging  
f. 
HIV-1 Genotype 
g. Total HIV-1 DNA by qPCR 
h. PBMC and Plasma Storage [only if large volume blood draw or leukapheresis are not 
done] 
i. 
Large Volume Blood Collection [as an alternative to leukapheresis] 
j. 
Leukapheresis [optional procedure] 
k. Gut biopsy [optional procedure]  
l. 
Lumbar Puncture [optional procedure] 
NOTE: Routine PBMC and plasma storage will be obtained from the large volume blood 
collection (or optional leukapheresis) at entry. Stored PBMC and plasma will be obtained at 
weeks 60 and 72, only if optional leukapheresis or large volume blood collection is not 
performed at those visits. 
 
 


ACTG A5354 
Primary Statistical Analysis Plan 
 
Page 16 of 20 
 
 
17 PRIMARY OUTCOME MEASURE 
The primary outcome measure defined in the protocol, section 10.2.1: 
 
Cell-associated HIV-1 DNA (CAHD) in 5 million blood-derived CD4+ T-cells (assayed by 
quantitative PCR [qPCR]) at week 48 on Step 1 
Note: Derivation of the primary outcome measures and any contributing datasets 
will be double-coded in accordance with the CBAR SOP, PROG.10083. 
For interim analyses, a summary of the availability of CA-DNA results will be generated. 
Table: Number (%) of participants with a week 48 visit on Step 1; Number (%) of participants 
with available CAHD results at week 48 on Step 1; Number (%) of participants not reaching 
week 48 on Step 1  
17.1 Primary Efficacy Analyses 
Note: Programs related to the analysis of the primary outcome measures listed in this 
section will require validation in accordance with the CBAR SOP, PROG.10083, 
including independent verification of results 
A table summarizing completeness of the primary outcome measure, and reasons for missing 
data (if any) will be provided, overall and by study group. 
Analysis of the primary outcome measure will be restricted to participants who maintain HIV-1 
RNA <50 copies/mL at week 48 with no ART interruption of ≥7 consecutive days and have 
available CAHD results from week 48 or week 49. Specifically, plasma HIV-1 RNA by 
commercial assay must be <50 copies/mL at week 48 with no prior virologic failure (defined as 
having two consecutive HIV-1 RNA >200 copies/mL at week 24 or later or at any time after 
achieving HIV-1 RNA <50 copies/mL). This study is designed to evaluate the effect of 
suppressive ART initiated in different stages of AHI on the establishment and persistence of 
HIV-1 reservoirs; this is the rationale for analyzing HIV-1 DNA only among virally suppressed 
participants and not in those with incompletely suppressed viremia (≥50 copies/ml).  
 
Participants who are excluded from the primary analysis will be presented in a listing, which 
displays the criteria by which they were excluded. 
 
The primary outcome measure will be summarized as a binary outcome, [0 copies] versus [>0 
copies] of CAHD per 5 million CD4+ T-cells, assessed separately and jointly by gag- and 
integrase-assays. In order for a participant to be considered as having 0 copies of CAHD, the 
participant must be found to have an undetectable CAHD result from both assays. The 
proportion of participants with ‘0 copies of CAHD’ will be compared pairwise between groups 
using Fisher’s exact test. A 95% confidence interval for the proportion estimated will be 
calculated using the exact binomial distribution. The analysis groups will be the study groups: 
Group 1 (Fiebig I/II), Group 2 (Fiebig III/IV), and Group 3 (Fiebig V), as defined by the results 
of the centralized testing from samples at study entry. 
 
CAHD per million CD4+ T-cells will also be summarized as a continuous variable, separately 
for gag- and integrase-assays, presenting N, median, Q1 and Q3 for the raw CAHD values (by 
study group and separately by Fiebig Stage).  CAHD per 5 million CD4+ T-cells will be divided 


ACTG A5354 
Primary Statistical Analysis Plan 
 
Page 17 of 20 
 
 
by 5 in order to evaluate CAHD per million CD4+ T-cells.  Undetectable CAHD results will be 
imputed as 0.01 copies. Additionally, summaries will be provided for log10-transformed CAHD 
per million CD4+ T-cells for gag- and integrase-assays, which will present N, mean, standard 
deviation, median, Q1, Q3 and min/max. Plots showing median, Q1 and Q3 values over time 
will also be presented, overall and by study group. In addition, scatter plots of gag- vs. 
integrase-assays will be presented with study groups marked with separate symbols. 
 
A supplemental analysis will use Wilcoxon rank sum test to compare the primary outcome 
measure on the continuous scale, separately for gag- and integrase-assays, between pairwise 
study groups (and between select Fiebig stages).  An additional supplemental analysis will use 
the Jonckheere–Terpstra test to assess potential trends across the study groups (and between 
Fiebig stages). We will also examine the primary outcome measure that includes participants 
with extended periods of ART interruption (≥7 consecutive days) who maintained HIV-1 RNA 
<50 copies/mL at week 48. For clades with sufficient data, supplemental sensitivity analyses 
will compare Fiebig stages stratified by HIV subtype.  
 
18 SECONDARY OUTCOME MEASURES 
Analysis of secondary outcome measures will use the same approach as the primary 
outcome measure if the outcome is binary. Wilcoxon rank-sum tests will be used to compare 
the continuous secondary outcome measures between groups. Jonckheere-Terpstra tests 
will be used to assess trends across the groups. Rank-based Spearman correlations will 
describe association between outcome measures. Scatter plots may also be used to present 
associations between outcome measures. Plots showing median, Q1 and Q3 values over 
time will also be presented, overall and by study group.  
18.1 
HIV-1-specific CD4+ and CD8+ T-cell responses to nef, gag, pol and env by flow 
cytometry while HIV-1 RNA is suppressed on ART  
The following HIV-1-specific responses will be summarized: 
a. Percent of CD4(8) cells expressing each of the 5 cytokines (CD40L, CD107a, IFNg, 
MIP1B, TNFa) in responses to each of the 4 protein stimulants (ENV, GAG, NEF and 
POL) 
Parent: CD3+CD4+ or CD3+CD8+ 
Cytokine Markers: CD40L+; CD107a+; IFNg+; MIP1B+; TNFa+ each individually 
b. Percent of CD4(8) cells expressing any cytokine (total response) to each of the 4 
protein stimulants 
Parent: CD3+CD4+ or CD3+CD8+ 
Cytokine Marker: CD40L+ or CD107a+ or IFNg+ or MIP1B+ or TNFa+ 


ACTG A5354 
Primary Statistical Analysis Plan 
 
Page 18 of 20 
 
 
c. Relative proportion of CD4(8) cells co-expressing any 2/3/4/5 cytokines 
(polyfunctional responses) to each of the 4 protein stimulants 
Parent: CD3+CD4+Cytokine+ or CD3+CD8+Cytokine+ 
For each n-cytokine polyfunctional response, the response is calculated as the total 
of the relative percent of cells expressing exactly n cytokines for the various 
combinations. For example, for 4-cytokine polyfunctional response, the various 
combination of the 4 positive cytokines are:   
CD40L-;CD107a+;IFNg+;MIP1B+;TNFa+ 
CD40L+;CD107a-;IFNg+;MIP1B+;TNFa+ 
CD40L+;CD107a+;IFNg-;MIP1B+;TNFa+ 
CD40L+;CD107a+;IFNg+;MIP1B-;TNFa+ 
CD40L+;CD107a+;IFNg+;MIP1B+;TNFa- 
And similarly, for 3-cytokine polyfunctional response, there are 10 various 
combinations with 3 positive cytokines.  
Note:  
For response a) and b) above, the results for a specific outcome for a specific 
participant/specimen-date are calculated by subtracting the corresponding background 
control value (media control). If the result would be less than zero after background 
subtraction, the result is set to zero. If the result of the active control SEB is less than the 
result of the background control for a particular outcome, the observation for that 
participant/specimen-date is treated as no result generated and is not included in the 
statistical analyses or plots. 
For response c), since the percentage is among cells which expressing at least one cytokine, 
there is no need to subtract the corresponding background control value. However, if the 
result of the active control SEB is less than the result of the background control for any 
cytokine response (response a above), then the observations with the parent 
CD3+CD4(8)+cytokine+ are treated as no result generated and is not include in the 
calculation of response c.  
18.2 
Cell-associated HIV-1 DNA in participants prior to ART initiation 
 
Pre-ART cell-associated HIV-1 DNA will be summarized using the same approach as week 48 
CAHD. 
 
Fold-changes (absolute change in the log10-tranformed measurements) from pre-ART 
measurement in CAHD will be summarized using a similar approach.  


ACTG A5354 
Primary Statistical Analysis Plan 
 
Page 19 of 20 
 
 
 
Correlations between selected immunology responses (IFNg+ and total response) and week 
48 CAHD will be examined using Spearman correlation coefficient (primary analysis 
population) with and without controlling for the study group. 
19 OTHER OUTCOME MEASURES 
Analysis of other outcome measures will use the same approach as the secondary outcome 
measure. The following exploratory outcome measure(s) will be included in the primary analysis 
report:  
19.1 Signs and symptoms of acute retroviral syndrome 
Table: summarizing number (%) of participants and the signs and symptoms of acute 
retroviral syndrome reported in the database, by MedDRA SOC, PT, grade and study group. 
19.2 Absolute CD4+ and CD8+ T-cell counts, CD4/CD8 ratio, and HIV-1 RNA prior to and 
after ART initiation  
 
See section 13. 
 
Other outcome measures from the protocol not listed here will be included in a separate report. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


ACTG A5354 
Primary Statistical Analysis Plan 
 
Page 20 of 20 
 
 
20 Associated Documents 
 
Attachment 1: Writing Team Roster 
Protocol Co-chairs, NIH Clinical Representatives, Statisticians, Clinical Trials Specialists, and 
selected Investigators.  
Attachment 2: Timetable for primary analysis and manuscript preparation 
Event 
Responsible party 
Weeks from primary 
completion date (PCD) 
Pre-closure conference call 
- 
Create specimen shipping and testing plan for 
laboratory data 
- 
Check about MTAs 
- 
Initiate DTAs 
CTS 
Protocol team 
 
NCC 
LDM 
PCD - 26 weeks 
 
Primary completion date (PCD) 
 
PCD: 12/2/2020 
Final specimen shipping request of samples to testing 
laboratories 
LDM 
PCD + 8 weeks 
Last Step 1 week 72 visit 
 
LFU 
SAP finalization 
Stats and Chairs 
LFU 
Clinical data entry termination 
Sites 
LFU + 1 week 
Initial database clean-up complete, including  
- 
DAERS reconciliation complete 
- 
TSDV complete 
 
PDM and LDM 
LFU + 12 weeks 
Laboratory data submitted to Frontier Science 
Assay laboratory 
PCD + 28 weeks 
Clinical database closure/freeze complete/eCRF sign-
off by site investigators 
PDM and Sites 
LFU + 10 weeks 
Processing & QC of laboratory data complete 
LDM 
LFU + 11 weeks 
Complete SDTM on production server 
SDTM Specialist 
LFU + 13 weeks 
Clinical database lock and primary laboratory database 
lock 
Chief Data Manager 
and LDM Leadership 
LFU + 16 weeks 
Final SDTM on production server 
SDTM Specialist 
LFU + 17 weeks 
Primary analysis report to Protocol Chairs/Writing 
Team 
Protocol statisticians 
LFU + 21 weeks 
 
 

Prot_001.pdf: 
A5354 
Effect of Antiretroviral Treatment Initiated During Acute 
HIV-1 Infection on Measures of HIV-1 Persistence and on 
HIV-1-Specific Immune Responses 
A Limited-Center Trial of the AIDS Clinical Trials Group 
(ACTG) 
NIAID CRMS # 12056 
This file contains the current ACTG A5324 protocol:  
Letter of Amendment #2, dated 17May2021
Letter of Amendment #1, dated 05Aug2020
Clarification Memorandum #1, dated 14Apr2020
Protocol Version 2.0, dated 31Dec2019


Letter of Amendment #2 
          Page 1 of 7 
17May2021 
ACTG A5354 Protocol Version 2.0 
Letter of Amendment #2 for: 
A5354 
Effect of Antiretroviral Treatment Initiated During Acute HIV-1 Infection on 
Measures of HIV-1 Persistence and on HIV-1-Specific Immune Responses 
A Limited-Center Trial of the AIDS Clinical Trials Group (ACTG) 
NIAID CRMS # 12056 
Letter of Amendment Date: 17May2021 
ACTG NETWORK COORDINATING CENTER 
Social & Scientific Systems, a DLH Holdings Company 
8757 Georgia Avenue, 12th Floor 
Silver Spring, MD  20910-3714 
Phone: 301-628-3000 
Fax: 301-628-3302
LETTER OF AMENDMENT #2 
DATE: 
May 17, 2021 
TO: 
ACTG CTU Principal Investigators, CRS Leaders, and CTU/CRS Coordinators 
FROM: 
A5354 Protocol Team  
SUBJECT: 
Letter of Amendment #2 for Protocol A5354 
The following information affects the A5354 study and must be forwarded to your 
institutional review board (IRB)/ethics committee (EC) as soon as possible for their 
information and review. This Letter of Amendment (LOA) must be approved by your 
IRB/EC before implementation.  
The following information may also affect the Sample Informed Consent. Your IRB/EC is 
responsible for determining the process of informing participants of the contents of this 
LOA. 
Upon receiving final IRB/EC and any other applicable regulatory entity approvals for this 
LOA, sites should implement the LOA immediately. Sites are still required to submit an 
LOA registration packet to the DAIDS Protocol Registration Office (PRO) at the 
Regulatory Support Center. A Protocol Signature Page (PSP) is appended for submission 
to the DAIDS Protocol Registration System (DPRS) as part of the LOA registration 
packet. Sites will receive a registration notification for the LOA once the DAIDS PRO 


Letter of Amendment #2 
          Page 2 of 7 
17May2021 
ACTG A5354 Protocol Version 2.0 
verifies that all required LOA registration documents have been received and are 
complete. An LOA registration notification from the DAIDS PRO is not required prior to 
implementing the LOA. A copy of the LOA registration notification, along with this letter 
and any IRB/EC correspondence, should be retained in the site’s regulatory file. 
This LOA is being implemented for the following reasons: 

revise the lists of secondary and exploratory objectives and their related outcome
objectives (items #2-5)

correct a clerical error in A5354v2 LOA#1, dated 08/05/20 (item #1)

incorporate DAIDS template language on the possibility for remote monitoring (item #6)

reconcile the Step 2 blood volume amounts in the Sample Informed Consent of
A5354v2, dated 12/31/19 (item #7).
The following are changes (noted in bold or strikethrough) to Protocol A5354, Version 2.0, 
12/31/19, titled "Effect of Antiretroviral Treatment Initiated During Acute HIV-1 Infection on 
Measures of HIV-1 Persistence and on HIV-1-Specific Immune Responses.” These changes will 
be included in the next version of the A5354 protocol if it is amended at a future date.  


Letter of Amendment #2 
          Page 3 of 7 
17May2021 
ACTG A5354 Protocol Version 2.0 
TABLE OF CONTENTS 
Page 
1.
Clarification Memo ................................................................................................................. 5
2.
Secondary Objectives ............................................................................................................ 5
3.
Exploratory Objectives ........................................................................................................... 5
4.
Secondary Outcome Measures ............................................................................................. 5
5.
Other Outcome Measures ..................................................................................................... 6
6.
Clinical Site Monitoring and Record Availability ..................................................................... 6
7.
Part 2 Study Schedule of the Sample Informed Consent of A5354v2 ................................... 7
PROTOCOL SIGNATURE PAGE ................................................................................................. 8 


Letter of Amendment #2 
          Page 4 of 7 
17May2021 
ACTG A5354 Protocol Version 2.0 
1.
Clarification Memo
In the A5354v2 LOA#1 (dated 08/05/20), the mentioned clarification memo (CM) dated
04/14/20 pertains to CM#1 (not CM#2 as referenced in the 2nd bullet of the introductory
paragraph on page 1).
2.
Secondary Objectives
In section 1.3, Secondary Objectives, the following modifications are being made, and
secondary objective 1.3.4 is being renumbered as 1.3.3.
1.3.1  To evaluate HIV-1-specific CD4+ and CD8+ T-cells by flow cytometry prior to ART
initiation and while HIV-1 RNA is suppressed on ART: 
a.
magnitude and distribution of CD4+ and CD8+ T-cells responses to
nef/tat/rev/vpr/vpu, gag, pol and env 
b.
quality of T-cell responses (i.e., frequency and type of polyfunctional responses)
1.3.2 To assess the amount of unspliced HIV-1 RNA in 5 million blood-derived CD4+ T- 
cells prior to ART initiation and while HIV-1 RNA is suppressed on ART. 
1.3.3 1.3.2 To assess cell-associated HIV-1 RNA to DNA ratio in participants with 
quantifiable HIV-1 DNA prior to ART initiation and while HIV-1 RNA is suppressed on 
ART. 
3.
Exploratory Objectives
In section 1.4, Exploratory Objectives, the objectives listed below are being added.
1.4.10 To assess the amount of unspliced HIV-1 RNA in blood-derived CD4+ T- cells
prior to and after ART initiation, including while HIV-1 RNA is suppressed on 
ART. 
1.4.11 To evaluate HIV-1-specific CD4+ and CD8+ T-cells by flow cytometry prior to 
ART initiation: 
a.
magnitude and distribution of CD4+ and CD8+ T-cells responses to major
structural and/or accessory HIV-1 proteins, such as nef, gag, pol, and env 
b.
quality of T-cell responses (i.e., frequency and type of polyfunctional
responses) 
1.4.12 To assess cell-associated HIV-1 RNA in participants prior to and after ART 
initiation. 
4.
Secondary Outcome Measures
In section 10.2.2, Secondary Outcome Measures, the modifications shown below are being
made.


Letter of Amendment #2 
          Page 5 of 7 
17May2021 
ACTG A5354 Protocol Version 2.0 
10.2.2.1  HIV-1-specific CD4+ and CD8+ T-cell responses to nef/tat/rev/vpr/vpu, gag, pol, 
and env by flow cytometry prior to ART initiation and while HIV-1 RNA is 
suppressed on ART 
10.2.2.2 Cell-associated HIV-1 RNA per 5 million CD4+ T-cells prior to ART initiation and 
while HIV-1 RNA is suppressed on ART 
10.2.2.3 10.2.2.2 Cell-associated HIV-1 RNA/DNA ratio in participants with detectable 
CAHD prior to ART initiation and while HIV-1 RNA is suppressed on ART 
5.
Other Outcome Measures
In section 10.2.3, Other Outcome Measures, the measures shown below are being added.
10.2.3.7 
HIV-1-specific CD4+ and CD8+ T-cell responses to nef, gag, pol, and env by
flow cytometry prior to and after ART initiation 
10.2.3.8 
Unspliced HIV-1 RNA per 5 million CD4+ T-cells prior to and after ART 
initiation  
10.2.3.9 
Cell-associated HIV-1 RNA prior to ART and after initiation. 
10.2.3.10 Signs and symptoms of acute retroviral syndrome 
10.2.3.11 Absolute CD4+ and CD8+ T-cell counts, CD4/CD8 ratio, and HIV-1 RNA prior 
to and after ART initiation 
6.
Clinical Site Monitoring and Record Availability
In section 12.3, Clinical Site Monitoring and Record Availability, the remote monitoring
language and reference listed below are being added to follow the first paragraph of
subsection 12.3.1.
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. 
Monitoring visits may be conducted on-site or remotely. Remote visits may 
include remote source document verification using methods specified for 
this purpose by NIAID. Remote monitoring visits may be performed in place 
of, or in addition to onsite visits to ensure the safety of study participants 
and data integrity [85]. The site will make available study documents for 
site monitors to review utilizing a secure platform that is HIPAA and 21 CFR 
Part 11 compliant. Potential platform options include: Veeva SiteVault, site-
controlled SharePoint or cloud-based portal, direct access to Electronic 


Letter of Amendment #2 
          Page 6 of 7 
17May2021 
ACTG A5354 Protocol Version 2.0 
Medical Record (EMR), and Medidata Rave Imaging Solution. Other secure 
platforms that are 21 CFR Part 11 compliant may be utilized, as allowed by 
the DAIDS Office of Clinical Site Oversight (OCSO). 
FDA Guidance on Conduct of Clinical Trials of Medical Products During the 
COVID-19 Public Health Emergency: Guidance for Industry, Investigators, 
and Institutional Review Boards, March 2020, Updated on January 27, 2021. 
Accessed at: https://www.fda.gov/media/136238/download 
7.
Part 2 Study Schedule of the Sample Informed Consent of A5354v2
In the Study Schedule for Part 2 of the Sample Informed Consent of A5354v2 (dated
12/31/19), the approximate amount of blood to be collected at Step 2 entry and every 24
weeks until week 144 has been corrected to be consistent with the Revised Laboratory
Processing Chart (revised date 10/23/20).
II.
Study Schedule for Part 2
Evaluation or Procedure 
Step 2 
Entry2 
Every 24 
weeks until 
week 1443 
Special 
Visit 5 
Leaving or 
Stopping the 
Study Early6 
Physical exam 
 
 
 
ART continued 
 
 
ART modifications 
 
 
 
 
Blood collected 
 
 
 
 
Pregnancy test 
 
If 
suspected 
 
Adherence support 
 
 
 
Approximate amount of 
blood 
up to 
83 mL 
23 mL 
up to  83 
19 mL/visit 
14 mL  
19 mL 


Letter of Amendment #2 
          Page 7 of 7 
17May2021 
ACTG A5354 Protocol Version 2.0 
Effect of Antiretroviral Treatment Initiated During Acute HIV-1 Infection on Measures of HIV-1 
Persistence and on HIV-1-Specific Immune Responses 
PROTOCOL 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 


 
Letter of Amendment #1 
          Page 1 of 6 
05Aug2020 
ACTG A5354 Protocol Version 2.0 
 
Letter of Amendment #1 for: 
 
A5354 
 
Effect of Antiretroviral Treatment Initiated During Acute HIV-1 Infection on 
Measures of HIV-1 Persistence and on HIV-1-Specific Immune Responses 
 
A Limited-Center Trial of the AIDS Clinical Trials Group (ACTG) 
 
NIAID CRMS # 12056 
 
Letter of Amendment Date: 05Aug2020 
 
 
ACTG NETWORK COORDINATING CENTER 
 
Social & Scientific Systems, a DLH Company 
8757 Georgia Avenue, 12th Floor 
Silver Spring, MD  20910-3714 
Phone: 301-628-3000 
Fax: 301-628-3302 
 
LETTER OF AMENDMENT 
 
DATE:  
August 5, 2020 
 
TO: 
 
ACTG CTU Principal Investigators, CRS Leaders, and CTU/CRS Coordinators 
 
FROM: 
A5354 Protocol Team  
 
SUBJECT: 
Letter of Amendment #1 for Protocol A5354 Version 2.0 
 
The following information affects the A5354 study and must be forwarded to each site’s 
institutional review board (IRB)/ethics committee (EC) as soon as possible for their 
information and review. This Letter of Amendment (LOA) must be approved by the site 
IRB/EC before implementation.  
 
The following information may also affect the Sample Informed Consent. The site IRB/EC 
is responsible for determining the process of informing participants of the contents of 
this LOA. 
 
Upon receiving final IRB/EC and any other applicable regulatory entity approvals for this 
LOA, sites should implement the LOA immediately. Sites are still required to submit an 
LOA registration packet to the DAIDS Protocol Registration Office (PRO) at the 
Regulatory Support Center. Sites will receive a registration notification for the LOA once 
the DAIDS PRO verifies that all required LOA registration documents have been received 
and are complete. An LOA registration notification from the DAIDS PRO is not required 
prior to implementing the LOA. A copy of the LOA registration notification, along with 
this letter and any IRB/EC correspondence, should be retained in the site’s regulatory 
file. 
 


Letter of Amendment #1 
          Page 2 of 6 
05Aug2020 
ACTG A5354 Protocol Version 2.0 
This LOA is being implemented for the following reasons: 

A team decision has been made that participants who have previously completed the final
study visit (week 72) and were discontinued from the study under Final Version 1.0 should
now be contacted and scheduled for screening in Step 2 of the Final Version 2.0. Step 2 of
the Final Version 2.0 is open to all participants who are currently in follow-up or who
previously completed the study under Final Version 1.0 and meet Step 2 criteria.

A team decision has been made to include instructions from A5354v2 Clarification Memo
(CM #2, dated 04/14/20) related to study visits that could not be conducted in person due to
SARS-CoV-2 pandemic (items #4 and #5 below).

A team decision has been made to include a new inclusion and exclusion criteria in Step 2
(items #2 and #3 below).

A team decision has been made to update the ARV interruption exclusion criterion for Step
2 (item #3 below).


Letter of Amendment #1 
          Page 3 of 6 
05Aug2020 
ACTG A5354 Protocol Version 2.0 
TABLE OF CONTENTS 
1.
Protocol Signature Page (PSP) ............................................................................................. 4
2.
Section 4.3, Step 2 Inclusion Criteria ..................................................................................... 4
3.
Section 4.4, Step 2 Exclusion Criteria .................................................................................... 4
4.
Section 5.1, Regimens, Administration, and Duration ........................................................... 4
5.
Section 6.3.3, Post-Entry Evaluations .................................................................................... 4


Letter of Amendment #1 
          Page 4 of 6 
05Aug2020 
ACTG A5354 Protocol Version 2.0 
The following are changes (noted in bold or strikethrough) to Protocol A5354, Version 2.0, 
12/31/19, titled "Effect of Antiretroviral Treatment Initiated During Acute HIV-1 Infection on 
Measures of HIV-1 Persistence and on HIV-1-Specific Immune Responses.” These changes will 
be included in the next version of the A5354 protocol if it is amended at a future date. Changes 
that have already been made (either by Letter of Amendment or by Clarification Memo) have 
been incorporated in the excerpted text shown below (and are no longer presented in bold or 
strikethrough).  
1.
Protocol Signature Page (PSP)
A Protocol Signature Page (PSP) was appended for submission to DAIDS Protocol
Registration System (DPRS) as part of the LOA registration packet.
2.
Section 4.3, Step 2 Inclusion Criteria
Updated to include a new inclusion as follows. All subsequent inclusion criteria were
renumbered.
4.3.2 At least one documented HIV-1 RNA result in each calendar year since Step 1
enrollment.
3.
Section 4.4, Step 2 Exclusion Criteria
a. Updated exclusion criterion as follows.
4.4.1 ARV interruption for greater than or equal to 7 consecutive days at any time after ART 
initiation and prior to entry into Step 2, including while on Step 1 or  after completion of Step 
1 and before initiation of Step 2. 
b. Included a new exclusion criterion as follows.
4.4.7 Any HIV-1 RNA >200 copies/mL after completion of Step 1 and before initiation 
of Step 2. 
4.
Section 5.1, Regimens, Administration, and Duration
Included the clarifications from A5354v2 CM#1 (dated 04/14/20) as follows.
Study treatment is defined as STR elvitegravir/cobicistat/emtricitabine/tenofovir alafenamide
(EVG/COBI/FTC/TAF) or bictegravir/emtricitabine/tenofovir alafenamide (BIC/FTC/TAF),
which will be provided through the study.
NOTES: Switching of ARV regimen is allowed (i.e., from EVG/COBI/FTC/TAF to
BIC/FTC/TAF, or vice versa, or to an alternate non-study-provided ART) without consulting
the CMC. Sites should ensure that participants who are enrolled into Step 2 have an
adequate supply of study-provided drug (i.e., up to a 3-month provision) until a participant is
able to come to the clinic for a study visit. If a participant is not able to return to the clinic for
any reason and needs a refill of study-provided drug, sites must contact their protocol team
pharmacist (via the Clinical Management Committee (CMC) at actg.cmcA5354@fstrf.org) to
establish the procedures for shipping study-provided drug to the participant.
5.
Section 6.3.3, Post-Entry Evaluations
a. Included the notation as follows.


Letter of Amendment #1 
          Page 5 of 6 
05Aug2020 
ACTG A5354 Protocol Version 2.0 
Step 2 Evaluations 
The Step 2 Registration evaluation may be combined with the Step 1 Week 72 visit. If the 
Step 2 Registration visit is not combined, then all Step 2 evaluations must be performed 
within 2 weeks after the final Step 1 visit. Those participants re-enrolling into the study after 
going off study at week 72 under protocol Version 1.0 will complete all evaluations listed in 
the Step 2 Registration column. 
NOTES: If a participant is unable to come to the clinic for the Step 2 registration visit 
for any of the reasons outlined in the subsection paragraphs, Remote Data Collection, 
of section 6.3.3, sites are encouraged to perform an alternative consenting process 
(e.g., telephone, telehealth). Sites should inform their IRB about this alternate consent 
method for Step 2.    
All visits following Step 2 registration will have a ± 60-day visit window.  
b. Included the clarifications from A5354v2 CM#1 (dated 04/14/20) as follows. Newly added
text are in bold. The subsection entitled, Remote Data Collection, will be incorporated at the 
end of section 6.3.3, Post-Entry Evaluations.  
Remote Data Collection 
It is preferable for study visits, as outlined in sections 6.1 and 6.2 Schedule of 
Evaluations (SOE), to be conducted in person. Study visits may be conducted remotely 
(e.g., telephone, telehealth) in the following situations:  

A participant is unable to attend a visit because of personal illness, illness among
others in his or her home, or local conditions or guidelines restricting travel to the clinic. 

The site is temporarily unable to conduct non-essential visits in the clinic; the site must
inform the CMC when it has to stop non-essential visits. 
Regardless of the situation, sites should document which visits were conducted remotely, 
attempt to obtain as much of the visit-specific required information, based on the SOE, as 
possible, and record it on the relevant eCRF. The impacted visits and rationale must be 
reported and documented, following instructions provided by the team or network 
leadership. 
Implementation of remote data collection is expected to be time-limited in relation to the 
SARS-CoV-2 pandemic. In consultation with ACTG Network leadership and the study 
sponsor, the protocol team will determine when remote data collection is no longer 
permitted. When such a determination is made, study sites will be formally notified and 
instructed to inform their IRBs/ECs as needed. 


Letter of Amendment #1 
          Page 6 of 6 
05Aug2020 
ACTG A5354 Protocol Version 2.0 
Effect of Antiretroviral Treatment Initiated During Acute HIV-1 Infection on Measures of HIV-1 
Persistence and on HIV-1-Specific Immune Responses 
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 


 
Clarification Memorandum #1 
          Page 1 of 3 
14Apr2020 
ACTG A5354 Protocol Version 2.0 
 
 
Clarification Memo #1 for: 
 
A5354 
 
Effect of Antiretroviral Treatment Initiated During Acute HIV-1 Infection on 
Measures of HIV-1 Persistence and on HIV-1-Specific Immune Responses 
 
A Limited-Center Trial of the AIDS Clinical Trials Group (ACTG) 
 
NIAID CRMS # 12056 
 
Clarification Memo Date: 14Apr2020 
 
 
ACTG NETWORK COORDINATING CENTER 
Social & Scientific Systems 
8757 Georgia Avenue, 12th Floor 
Silver Spring, MD  20910-3714 
Phone: 301-628-3000 
Fax: 301-628-3302 
 
 
CLARIFICATION MEMO 
 
DATE:  
April 14, 2020 
 
TO: 
 
ACTG CTU Principal Investigators, CRS Leaders, and CTU/CRS Coordinators 
 
FROM: 
A5354 Protocol Team  
 
SUBJECT: 
Clarification Memo #1 for A5354 Protocol Version 2.0 (SARS-CoV-2 Pandemic) 
 
 
This clarification memo (CM) does not result in a change in the protocol informed 
consent document. The Division of AIDS (DAIDS) has determined that these protocol 
changes and clarifications should be implemented immediately in response to the SARS-
CoV-2 pandemic, which poses a safety risk to participants and site staff. Sites do not 
need institutional review board (IRB) approval prior to implementing this CM. 
 
DAIDS does not require sites to forward this CM to their IRB; however, sites must follow 
their IRB's policies and procedures. If IRB review of CMs is required at a site, the site 
must submit this document for review. 
 
Each site should file a copy of this CM with the protocol for reference. 
 
The team is implementing this CM to provide guidance to sites about the final study visit 
completion under Final Version 1.0, the Step 2 registration under Final Version 2.0, alternate 
methods to conducting the study visits, including data collection and documentation, and 
continuation of ART regimen for the entire duration of the study.  


 
Clarification Memorandum #1 
          Page 2 of 3 
14Apr2020 
ACTG A5354 Protocol Version 2.0 
 
 
The following are clarifications (noted in bold) to Protocol A5354, Version 2.0, 12/31/19, titled 
“Effect of Antiretroviral Treatment Initiated During Acute HIV-1 Infection on Measures of HIV-1 
Persistence and on HIV-1-Specific Immune Responses.” These clarifications will be included in 
the next version of the A5354 protocol if it is amended at a future date. 
 
1. Only participants who are currently in follow-up and have completed the final study visit 
(week 72) under Final Version 1.0 AND who provide consent on their willingness to 
participate in Final Version 2.0 will be permitted to register to Step 2 of the study. NOTE: 
Participants who have already been discontinued from the study are not permitted to re-
enroll at this time.  
 
If a participant is unable to come to the clinic for the Step 2 registration visit, sites are 
encouraged to perform an alternative consenting process (e.g., telephone, telehealth) 
provided sites inform their IRB about this alternate consent method.    
 
2. Section 5.1, Regimens, Administration, and Duration, was updated to include the following 
clarifications: 
 
Study treatment is defined as STR elvitegravir/cobicistat/emtricitabine/tenofovir alafenamide 
(EVG/COBI/FTC/TAF) or bictegravir/emtricitabine/tenofovir alafenamide (BIC/FTC/TAF), 
which will be provided through the study.  
 
NOTES: Switching of ARV regimen is allowed (i.e., from EVG/COBI/FTC/TAF to 
BIC/FTC/TAF, or vice versa, or to an alternate non-study-provided ART) without consulting 
the CMC. Sites should ensure that participants who are enrolled into Step 2 have an 
adequate supply of study-provided drug (i.e., up to a 3-month provision) until a 
participant is able to come to the clinic for a study visit. If a participant is not able to 
return to the clinic for any reason and needs a refill of study-provided drug, sites 
must contact their protocol team pharmacist (via the Clinical Management Committee 
(CMC) at actg.cmcA5354@fstrf.org) to establish the procedures for shipping study-
provided drug to the participant. 
   
3. Section 6.3.3, Post-Entry Evaluations, was updated to include the following clarifications at 
the end of the section: 
 
Remote Data Collection 
Study visits may be conducted remotely (e.g., telephone, telehealth) in the following 
situations:  
 
A participant is unable to attend a visit because of personal illness, illness 
among others in his or her home, or local conditions or guidelines restricting 
travel to the clinic.  
 
The site is temporarily unable to conduct non-essential visits in the clinic; the 
site must inform the CMC when it has to stop non-essential visits. 
 
Regardless of the situation, sites should document which visits were conducted 
remotely, attempt to obtain as much of the visit-specific required information, based 
on the SOE, as possible, and record it on the relevant eCRF. The impacted visits and 
rationale must be reported and documented, following instructions provided by the 
team or network leadership. 
 


 
Clarification Memorandum #1 
          Page 3 of 3 
14Apr2020 
ACTG A5354 Protocol Version 2.0 
 
Implementation of remote data collection is expected to be time-limited in relation to 
the SARS-CoV-2 pandemic. In consultation with ACTG Network leadership and the 
study sponsor, the protocol team will determine when remote data collection is no 
longer permitted. When such a determination is made, study sites will be formally 
notified and instructed to inform their IRBs/ECs as needed. 
 
 


 
A5354 
 
Effect of Antiretroviral Treatment Initiated During Acute HIV-1 Infection on 
Measures of HIV-1 Persistence and on HIV-1-Specific Immune Responses 
 
A Limited-Center Trial of the AIDS Clinical Trials Group (ACTG) 
 
 
Sponsored by: 
 
 
The National Institute of Allergy 
and Infectious Diseases 
 
 
Industry Support Provided by: 
Gilead Sciences, Inc. 
 
 
Non-IND Protocol 
 
 
 
The ACTG HIV Reservoirs and Viral Eradication  
(CURE) Transformative Science Group:  
Pablo Tebas, MD, Chair 
 
Protocol Co-Chairs 
Trevor Crowell, MD, PhD  
 
Eric Daar, MD 
 
Protocol Vice Chair: 
Javier Lama, MD, MPH 
 
DAIDS Clinical Representative:  
Lawrence Fox, MD, PhD 
 
Clinical Trials Specialist: 
Jennifer Tiu, MPH 
 
 
 
 
 
FINAL Version 2.0 
December 31, 2019 
 


A5354 
 
 
FINAL Version 2.0 
 
 
12/31/19 
 
 
Effect of Antiretroviral Treatment Initiated During Acute HIV-1 Infection on Measures of 
HIV-1 Persistence and on HIV-1-Specific Immune Responses 
 
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 
 


 
 
A5354 
 
 
FINAL Version 2.0 
 
 
12/31/19 
 
 
TABLE OF CONTENTS 
Page 
SITES PARTICIPATING IN THE STUDY .................................................................................... 5 
PROTOCOL TEAM ROSTER ..................................................................................................... 6 
STUDY MANAGEMENT ........................................................................................................... 10 
GLOSSARY OF PROTOCOL-SPECIFIC TERMS ..................................................................... 13 
SCHEMA .................................................................................................................................. 14 
1.0 
HYPOTHESIS AND STUDY OBJECTIVES ................................................................... 17 
1.1 
Hypotheses ........................................................................................................ 17 
1.2 
Primary Objective ............................................................................................... 17 
1.3 
Secondary Objectives ........................................................................................ 17 
1.4 
Exploratory Objectives ....................................................................................... 18 
2.0 
INTRODUCTION ........................................................................................................... 19 
2.1 
Background ........................................................................................................ 19 
2.2 
Rationale ........................................................................................................... 33 
3.0 
STUDY DESIGN ........................................................................................................... 34 
4.0 
SELECTION AND ENROLLMENT OF PARTICIPANTS ................................................ 36 
4.1 
Step 1 Inclusion Criteria for Group 1 ................................................................ 36 
4.2 
Step 1 Exclusion Criteria for Group 1 ............................................................... 37 
4.3 
Step 2 Inclusion Criteria .................................................................................. 38 
4.4  
Step 2 Exclusion Criteria ................................................................................. 39 
4.5 
Study Enrollment Procedures............................................................................. 40 
4.6  
Coenrollment Guidelines .................................................................................... 41 
5.0 
STUDY TREATMENT ................................................................................................... 42 
5.1 
Regimens, Administration, and Duration ............................................................ 42 
5.2 
Study Product Formulation and Preparation ....................................................... 42 
5.3 
Pharmacy: Product Supply, Distribution, and Accountability .............................. 42 
5.4 
Concomitant Medications ................................................................................... 43 
6.0 
CLINICAL AND LABORATORY EVALUATIONS ........................................................... 48 
6.1 
Schedule of Evaluations (SOE) for Step 1 ....................................................... 48 
6.2 
SOE for Step 2 .................................................................................................. 50 
6.3 
Timing of Evaluations ......................................................................................... 51 
6.4 
Instructions for Evaluations ................................................................................ 55 
7.0 
ADVERSE EVENTS AND STUDY MONITORING ......................................................... 63 
7.1 
Definition of Adverse Events ............................................................................ 63 
7.2 
Adverse Event Collection Requirements .......................................................... 64 
7.3 
Expedited Adverse Event (EAE) Reporting to DAIDS ........................................ 64 
7.4 
Study Monitoring ............................................................................................... 65 
8.0 
CLINICAL MANAGEMENT ISSUES .............................................................................. 65 
8.1 
Toxicity .............................................................................................................. 66 


A5354 
 
 
FINAL Version 2.0 
 
 
12/31/19 
 
CONTENTS (Cont’d) 
Page 
 
8.2 
Rash .................................................................................................................. 68 
8.3 
Diarrhea ............................................................................................................. 68 
8.4 
Nausea/Vomiting................................................................................................ 69 
8.5 
Liver Enzyme Elevations .................................................................................... 69 
8.6 
Headache .......................................................................................................... 70 
8.7 
Hypophosphatemia ............................................................................................ 70 
8.8  
Renal Insufficiency ............................................................................................. 71 
8.9 
Pregnancy and Breastfeeding ............................................................................ 71 
8.10 
Lumbar Puncture ............................................................................................... 72 
8.11 
Leukapheresis ................................................................................................... 72 
8.12 
Gut Biopsy ......................................................................................................... 72 
9.0 
CRITERIA FOR DISCONTINUATION ........................................................................... 73 
9.1 
Premature Study Drug Discontinuation .............................................................. 73 
9.2 
Premature Study Discontinuation ...................................................................... 73 
10.0 
STATISTICAL CONSIDERATIONS ............................................................................... 73 
10.1 
General Design Issues ....................................................................................... 73 
10.2 
Outcome Measures ............................................................................................ 74 
10.3 
Randomization and Stratification ........................................................................ 75 
10.4 
Sample Size and Accrual ................................................................................... 75 
10.5 
Data and Safety Monitoring .............................................................................. 76 
10.6 
Analyses ............................................................................................................ 77 
11.0 
PHARMACOLOGY PLAN .............................................................................................. 78 
12.0 
DATA COLLECTION AND MONITORING ..................................................................... 78 
12.1 
Records to Be Kept ............................................................................................ 78 
12.2 
Role of Data Management ................................................................................. 78 
12.3 
Clinical Site Monitoring and Record Availability .................................................. 79 
13.0 
PARTICIPANTS ............................................................................................................ 79 
13.1 
IRB Review and Informed Consent .................................................................... 79 
13.2 
Participant Confidentiality ................................................................................... 79 
13.3 
Study Discontinuation ........................................................................................ 79 
14.0 
PUBLICATION OF RESEARCH FINDINGS .................................................................. 80 
15.0 
BIOHAZARD CONTAINMENT ...................................................................................... 80 
16.0 
REFERENCES .............................................................................................................. 81 
APPENDIX I:  SAMPLE INFORMED CONSENT ...................................................................... 86 
APPENDIX II: CONSENT FOR OPTIONAL PROCEDURES AND SAMPLES 
COLLECTION AFTER WEEK 48 ON STEP 1 ............................................................ 112 
 


 
5 
A5354 
 
 
FINAL Version 2.0 
 
 
12/31/19 
 
 
SITES PARTICIPATING IN THE STUDY 
 
A5354 will be implemented at US and non-US clinical research sites (CRSs) with active 
screening programs for acute HIV-1 infection (AHI).  
 


 
6 
A5354 
 
 
FINAL Version 2.0 
 
 
12/31/19 
 
 
PROTOCOL TEAM ROSTER 
 
Co-Chairs 
Trevor Crowell, MD, PhD 
US Military HIV Research Program 
6720-A Rockledge Drive, Suite 400 
Bethesda, MD 20817 
Phone: 301-500-3990 
Fax:   301-500-3666 
E-mail:  tcrowell@hivresearch.org 
 
Eric Daar, MD 
Harbor-UCLA Medical Center CRS 
1124 W. Carson Street 
CDCRC Building, 205 
Torrance, CA 90502 
Phone: 424-201-3000 
Fax:   310-782-2964 
E-mail:   edaar@labiomed.org 
 
Vice Chair 
Javier Lama, MD, MPH 
San Miguel CRS 
Av Almirante Miguel Grau  
1010 Barranco Lima, 4 Peru 
Phone:   51-1-2067800 Ext. 407 
Fax:   51-1-4472479 
E-mail: jrlama@impactaperu.org 
 
DAIDS Clinical Representative 
Lawrence Fox, MD, PhD 
HIV Research Branch 
NIH/NIAID/DAIDS/TRP/HIVRB  
5601 Fishers Lane, Room 9E41A 
Rockville, MD 20852 
Phone:   240-627-3069 
E-mail:   lfox@niaid.nih.gov 
Clinical Trials Specialist 
Jennifer Tiu, MPH 
ACTG Network Coordinating Center 
Social & Scientific Systems 
8757 Georgia Avenue, 12th Floor 
Silver Spring, MD 20910-3714 
Phone:  301-628-3371 
Fax:  301-628-3302 
E-mail:  jtiu@s-3.com 
Statisticians 
Justin Ritz, MS 
Statistical and Data Analysis Center 
Harvard T.H. Chan School of Public Health 
FXB Building, Room 510 
Boston, MA 02115 
Phone:   617-432-3034 
Fax:   617-432-3163 
E-mail:   jritz@sdac.harvard.edu 
 
Lu (Summer) Zheng, PhD 
Statistical and Data Analysis Center 
Harvard T.H. Chan School of Public Health 
FXB Building, Room 613, 651 Huntington Ave 
Boston, MA 02115-6017 
Phone:   617-432-3021 
Fax:   617-432-2843 
E-mail:   szheng@sdac.harvard.edu 
 
Data Manager 
Tydie Higgins, MHA 
Frontier Sciences & Technology 
Research Foundation, Inc. 
4033 Maple Road 
Amherst, NY 14226 
Phone:   716-834-0900  
E-mail:   thiggins@frontierscience.org 
 
DAIDS Pharmacist 
Oladapo Alli, PharmD 
Pharmaceutical Affairs Branch 
Division of AIDS/OCSO/NIAID/NIH 
5601 Fishers Lane,  
Room 9E16, MSC #9832 
Bethesda, MD 20892 
Phone:   240-627-3593 
Fax:   240-627-3112 
E-mail:   oladapo.alli@nih.gov 
 


 
7 
A5354 
 
 
FINAL Version 2.0 
 
TEAM ROSTER (Cont'd) 
12/31/19 
 
Immunologist 
Scott Sieg, PhD 
Case Western Reserve University 
Biomedical Research Building 
Room 1020 
2109 Adelbert Road 
Cleveland, OH 44106 
Phone:   216-368-6594 
Fax:   216-368-5415 
E-mail: sfs2@case.edu 
 
Virologists 
John W. Mellors, MD 
University of Pittsburgh CTU 
University of Pittsburgh School of Medicine 
Scaife Hall 
3550 Terrace Street, Suite 818 
Pittsburgh, PA 15261 
Phone:   412-624-8512 
Fax:   412-383-7982 
E-mail:   jwm1@pitt.edu 
 
Gert U. van Zyl, MBChB, FCPath (SA), PhD 
Division of Medical Virology  
Faculty of Medicine and Health Sciences  
Stellenbosch University/FAMCRU 
P.O. Box 19063 
Tygerberg 7505 
Western Cape Province 
South Africa 
Phone:  27-21-938961 
Fax:   27-21-9389361 
E-mail:  guvz@sun.ac.za 
 
Investigators 
Roberto Arduino, MD 
Houston AIDS Research Team CRS 
UTHSC-H 
6431 Fannin, MSB 6.120 
Houston, TX 77030 
Phone:   713-500-6731 
Fax:   713-500-0610 
E-mail:   Roberto.C.Arduino@uth.tmc.edu 
 
Investigators (Cont’d) 
Benjamin Chi, MD, MSc 
Department of Obstetrics and Gynecology 
University of North Carolina at Chapel Hill 
Campus Box 7570, MBRB 4300C 
Chapel Hill, NC 27599 
Phone:   919-445-4147 
E-mail:   bchi@med.unc.edu  
 
Susan E. Cohn, MD, MPH 
Division of Infectious Diseases  
Northwestern University Feinberg  
School of Medicine 
645 N. Michigan Avenue, Suite 900 
Chicago, IL 60611 
Phone:   312-926-3693 
Fax:   312-695-5088  
E-mail:   susan-cohn@northwestern.edu 
 
Ann Collier, MD 
University of Washington  
Harborview Medical Center 
Box 359929, 325 9th Avenue 
Seattle, WA 98104 
Phone:   206-744-3293 
Fax:   206-744-3483 
E-mail:   acollier@u.washington.edu 
 
Robert Coombs, MD 
University of Washington AIDS CRS 
University of Washington,  
Retrovirology Laboratory 
Research and Training Building, 7th Floor 
325 9th Avenue 
Seattle, WA 98104-2420 
Phone:   206-897-5205 
Fax:   206-897-5203 
E-mail:   bcoombs@u.washington.edu 
 
Joseph Eron, MD 
UNC AIDS CRS 
Bioinformatics Building 
130 Mason Farm Road, Suite 210  
Chapel Hill, NC 27599-7215 
Phone:  919-843-2722 
Fax:   919-966-6714 
E-mail:   jeron@med.unc.edu 


 
8 
A5354 
 
 
FINAL Version 2.0 
 
TEAM ROSTER (Cont'd) 
12/31/19 
 
Investigators (Cont’d) 
Sonya Heath, MD 
Alabama CRS 
BBRB 542, 845 19th Street South 
Birmingham, AL 35294-2170 
Phone:   205-996-2371 
Fax:   205-996-7200 
E-mail:   heaths@uab.edu  
 
Brenda Hoagland, MD 
Instituto de Pesquisa Clinica Evandro 
Chagas CRS (IPEC) CRS 
Fundacao Oswaldo Cruz 
Avenida Brasil 4365 Manguinhos 
Rio de Janeiro, 21040-900 
Brazil 
Phone:   55-21-38659623 
Fax:   55-21-25644933 
E-mail:   brenda.hoagland@ipec.fiocruz.br 
 
Eugene Kroon, MD 
Thai Red Cross AIDS Research Center 
104 Radjdamri Road Pathumwan 
Bangkok, 10330 Thailand 
Phone:   66-89006-4746 
Fax:   66-2-254-2567 
E-mail:   eugene.k@searchthailand.org 
 
Susan Little, MD 
UCSD Antiviral Research Center 
Mail Code 8208 200 West Arbor Drive 
San Diego, CA 92103 
Phone:   619-543-8080 
Fax:   619-543-5066 
E-mail:   slittle@ucsd.edu 
 
Gonasagrie Nair, MBChB, MPH 
CAPRISA eThekwini CRS 
University of KwaZulu-Natal 
Doris Duke Medical Research Institute 
2nd floor 
Private Bag X7 
Durban, KwaZulu-Natal 4001 
South Africa 
Phone: 27-31-2601972 
E-mail: nairg1@ukzn.ac.za 
 
Investigators (Cont’d) 
Deborah Persaud, MD 
Division of Infectious Diseases 
Department of Pediatrics  
Johns Hopkins University School of 
Medicine. PMOB 3-3151 
200 North Wolfe Street, Room 3151 
Baltimore, MD 21287 
Phone:   443-287-3733 
Fax:   410-614-1315 
E-mail:   dpers@jhmi.edu 
 
Sharon Riddler, MD, MPH 
University of Pittsburgh CRS 
Keystone Building, Suite 510 
3520 Fifth Avenue 
Pittsburgh, PA 15213-2582 
Phone:   412-383-1741 
Fax:   412-383-2900 
E-mail:   riddler@pitt.edu 
 
Magdalena Sobieszczyk, MD, MPH 
Columbia Physicians & Surgeons CRS 
630 West 168th Street, PH 8 West 876 
Columbia University Medical Center 
Department of Medicine  
Division of Infectious Diseases 
New York, NY 10032 
Phone:   212-305-7185 
Fax:   212-305-7290 
E-mail:   mes52@cumc.columbia.edu 
 
Field Representative 
Dimas Kliemann, MD 
Servico de Infectologia 
Av. Francisco Trein, 596 
Cristo Redentor 
Porto Alegre  
Rio Grande do Sul 91350-200 
Brazil 
Phone:   55-51-33572126 
E-mail:  dimaskliemann@gmail.com 
 


 
9 
A5354 
 
 
FINAL Version 2.0 
 
TEAM ROSTER (Cont'd) 
12/31/19 
 
Laboratory Technologist 
LuAnn Borowski, MSc 
Pittsburgh CRS 
Infectious Disease 
Parran Hall, Room 523, GSPH 
130 DeSoto Street 
Pittsburgh, PA 15261 
Phone:   412-624-0582 
Fax:   412-648-1286 
E-mail:   luann@pitt.edu 
 
Community Scientific Subcommittee (CSS) 
Representative 
Andrew Kaytes 
3984 Illinois Street, #4 
San Diego, CA 92104 
Phone:   619-840-5286 
Fax:   619-546-8541 
E-mail:   sitnfu@yahoo.com 
 
International Site Specialist 
Morgan Gapara 
ACTG Network Coordinating Center 
Social & Scientific Systems, Inc. 
4505 Emperor Boulevard. Suite 400 
Durham, NC 27703 
Phone: 919-287-4503 
Fax:   919-941-9349 
E-mail: mgapara@s-3.com 
 
Industry Representative  
James Rooney, MD 
Gilead Sciences, Inc. 
333 Lakeside Drive 
Foster City, CA 94404 
Phone: 650-522-5708 
Fax:   650-522-5854 
E-mail: Jim.Rooney@gilead.com 
 
Laboratory Data Manager 
Kyle Whitson, MA 
Frontier Science & Technology Research 
Foundation 
4033 Maple Road 
Amherst, NY 14226 
Phone: 716-340-0900 ext. 7273 
E-mail: whitson@frontierscience.org 
Laboratory Specialist 
Deborah Anisman-Posner, BA, CPT 
ACTG Laboratory Center at UCLA 
11075 Santa Monica Boulevard 
Suite 200 
Los Angeles, CA 90025 
Phone: 310-825-5382 
E-mail: danisman@milabcentral.org 
 
 


 
10 
A5354 
 
 
FINAL Version 2.0 
 
 
12/31/19 
 
 
STUDY MANAGEMENT 
 
Most questions concerning this protocol should be sent to actg.corea5354@fstrf.org via e-mail. 
The appropriate team member will respond with a "cc" to the appropriate team e-mail group. A 
response should generally be received within 24 hours (Monday-Friday). 
 
Protocol E-mail Group 
Sites should contact the Computer Support Group at the Data Management Center (DMC) as 
soon as possible to have the relevant personnel at the site added to the actg.protA5354 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, Fiebig staging, primary endpoint determination outcome, 
alternative study medication use (e.g., locally available regimens), clinical management, 
concomitant medications, and coenrollment, contact the study’s CMC, which is a subgroup of 
the A5354 protocol team.  
• 
Send an e-mail message to actg.cmcA5354@fstrf.org. Include the protocol number, patient 
identification number (PID), and a brief relevant history. 
 
Laboratory 
For questions specifically related to laboratory tests, contact the protocol Immunologist and 
Virologists.  
• 
Send an e-mail message to actg.cmcA5354@fstrf.org (ATTENTION: Scott Sieg 
[Immunologist] and John Mellors and Gert van Zyl [Co-Virologists]). 
 
Data Management 
• 
For nonclinical questions about transfers, inclusion/exclusion criteria, electronic case report 
forms (eCRFs), registration, and other data management issues, contact the Data Manager. 
Electronic CRFs (eCRFs) completion guidelines and participant completed CRFs can be 
downloaded from the FSTRF website at www.fstrf.org. 
• 
For transfers, reference the Patient Transfer from Site to Site SOP 119, and contact Tydie 
Higgins at thiggins@fstrf.org directly.  
• 
For other questions, send an e-mail message to actg.teamA5354@fstrf.org (ATTENTION: 
Tydie Higgins). Sites may use their discretion to determine whether the CMC should be 
copied on these messages. 
• 
Include the protocol number, PID, and a detailed question. 
 
Participant Registration 
For participant registration questions or problems and study identification number SID lists.  
• 
Send an e-mail message to rando.support@fstrf.org or call the Statistical and Data Analysis 
Center (SDAC)/DMC Randomization Desk at 716-834-0900 x7301.    
 


 
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Computer and Screen Problems  
Contact the SDAC/DMC programmers.  
• 
Send an e-mail message to actg.usersupport@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.corea5354@fstrf.org (ATTENTION: Jennifer Tiu). 
 
Copies of the Protocol 
To request a hard copy of the protocol, send a message to ACTGNCC@s-3.com via e-mail. 
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 at US sites, contact the Clinical Trials 
Specialist.  
• 
Send an e-mail message to actg.teamA5354@fstrf.org (ATTN: Jennifer Tiu). 
 
For questions related to protocol activation at non-US sites, contact the ACTG Site 
Coordination Group.  
• 
Send an email message to actgsitecoordination@s-3.com 
 
Study Product 
For questions or problems regarding study product, dose, supplies, records, and returns, 
contact Oladapo Alli, Protocol Pharmacist, at oladapo.alli@nih.gov. 
 
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.  
 
Telephone Calls 
Sites are responsible for documenting any phone calls made to A5354 team members.  
• 
Send an e-mail to actg.corea5354@fstrf.org. 
 


 
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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 
 
Ab 
antibody 
AE 
adverse event 
Ag 
antigen 
AHI 
acute HIV-1 infection 
ALT 
alanine aminotransferase 
ART 
antiretroviral therapy/treatment 
AST 
aspartate aminotransferase 
ARV 
antiretroviral (or antiretroviral drugs) 
β-HCG 
β-human chorionic gonadotropin 
BIC/FTC/TAF 
bictegravir/emtricitabine/tenofovir alafenamide  
CAHD 
cell-associated HIV-1 DNA  
CDC 
Centers for Disease Control and Prevention 
CMC 
Clinical Management Committee 
CMIA 
chemiluminescence immunoassay 
CNS 
central nervous system 
CrCl 
creatinine clearance 
CSF  
cerebrospinal fluid 
DHHS 
US Department of Health and Human Services 
EC 
Ethics Committee 
EIA 
enzyme immunoassay 
EVG/COBI/FTC/TAF elvitegravir/cobicistat/emtricitabine/tenofovir alafenamide 
FDA 
Food and Drug Administration 
HLA 
human leukocyte antigen 
IRB 
Institutional Review Board 
LTR 
long terminal repeat 
PBMC 
peripheral blood mononuclear cells 
PR 
protease 
qPCR 
quantitative PCR 
RE 
regulatory entity 
RT 
reverse transcriptase 
SANBS 
South African National Blood Service 
S/CO 
signal-to-cutoff ratio 
SMC 
Study Monitoring Committee 
STR 
single tablet regimen 
VF 
virologic failure 
WB 
Western blot 


 
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SCHEMA 
 
 
A5354 
Effect of Antiretroviral Treatment Initiated During Acute HIV-1 Infection on Measures of HIV-1 
Persistence and on HIV-1-Specific Immune Responses 
 
 
DESIGN 
This is a phase II, prospective, open-label two-step study to measure the 
effects of early antiretroviral therapy (ART) on the establishment of HIV-1 
reservoir and HIV-1-specific immunity. Treatment-naïve participants with 
acute HIV-1 infection (AHI) will have an enrollment visit that will include 
the immediate initiation of ART. The primary endpoint is cell-associated 
HIV-1 DNA (CAHD) in 5 million blood-derived CD4+ T-cells assayed by 
quantitative PCR (qPCR) at week 48 on Step 1.  
 
A subset of participants who have completed week 48 on Step 1 will 
be consented for the optional cerebrospinal fluid collection via lumbar 
puncture (LP) and gut biopsy via flexible sigmoidoscopy. A target of 25 
participants are estimated to have each of the above mentioned 
optional procedure. Participants may consent to one or both of these 
optional procedures, which will be performed at any time on Step 1 from 
week 60 to week 72 in willing participants.  
 
Willing participants who have completed Step 1 follow-up without 
meeting the criteria for study discontinuation (refer to section 9.2) 
will be encouraged to continue on Step 2 and complete study 
evaluations through 144 weeks of Step 2 follow-up. Participants who 
had previously completed the study at week 72 under protocol 
Version 1.0 will be allowed to re-enroll in protocol Version 2.0 if, in 
the interim, these participants meet Step 2 eligibility criteria. The 
“re-enrolled” participants will be placed in the Fiebig group in which 
they were initially enrolled in protocol Version 1.0.  
 
The Fiebig stage-classification system will be used to characterize the 
progression from HIV-1 exposure to HIV-1 seroconversion at the time of 
ART initiation. Plasma and serum samples will be collected at the time of 
ART initiation and the results of the Fiebig stage at ART initiation will be 
available to sites within 12 weeks. In this study, the Fiebig I-V stages of 
interest will be simplified into three study groups (based on HIV-1 
antibody diagnostic profile at the time of ART initiation) as described 
below.  
 


 
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Group 1: Fiebig I/II (non-reactive HIV-1 antibody) 
Group 2: Fiebig III/IV (reactive HIV-1 antibody and negative or 
indeterminate results on the Western blot or Geenius HIV-
1/HIV-2) (This study group is closed to enrollment under 
protocol Version 1.0.) 
Group 3: Fiebig V (reactive HIV-1 antibody and positive Western blot or 
Geenius HIV-1/HIV-2 without p31 band) (This study group is 
closed to enrollment under protocol Version 1.0.) 
 
Participants who meet criteria for enrollment and are found to be in 
Group 2 or 3 based upon Fiebig staging at time of ART initiation will 
be followed in those groups per protocol. It is possible that a small 
number of participants will be determined to be in Fiebig VI (positive 
Western blot or Geenius HIV-1/HIV-2 with p31 band) based on analysis of 
the entry samples even though these participants are not specifically 
targeted for enrollment in this study. Participants who are determined to 
be in Fiebig VI will be followed on the study for no more than 24 weeks 
on Step 1, allowing ample time for them to pursue alternative sources for 
ART. Confirmed Fiebig VI and HIV negative participants will be 
replaced.  
 
The Clinical Management Committee of the A5354 protocol team will 
review the Fiebig staging. 
 
DURATION 
Up to 216 weeks (72 weeks on Step 1 and 144 weeks on Step 2). 
 
SAMPLE SIZE 
A total of 196 participants. Each study group had a target enrollment of 50 
participants under protocol Version 1.0. From these study groups, up to 
25 eligible participants will be asked to consent to each optional 
procedure.  
 
POPULATION 
Men and women 18 years and older with AHI.  
 
NOTE: Pregnant and breastfeeding women may enroll in the study.  
 
REGIMEN 
The antiretroviral (ARV) regimen provided through the study is the single 
tablet regimen elvitegravir/cobicistat/emtricitabine/tenofovir alafenamide 
(EVG/COBI/FTC/TAF) or bictegravir/emtricitabine/tenofovir 
alafenamide (BIC/FTC/TAF). Other non-study-provided ARV regimens 
will be allowed for participants who are pregnant, breastfeeding, or 
unable/unwilling to take EVG/COBI/FTC/TAF or BIC/FTC/TAF, or for 
participants whose local health care/primary care provider prefers starting 
a different initial ARV regimen. 
 
 
 


 
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Schema Figure 1: Study Weeks for Step 1 
 
 
Schema Figure 2: Study Weeks for Step 2 
 
 


 
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1.0 
HYPOTHESIS AND STUDY OBJECTIVES 
 
1.1 
Hypotheses 
 
Timing of antiretroviral therapy (ART) during different stages of acute HIV-1 infection 
(AHI) will be predictive of the magnitude and characteristics of HIV-1 reservoirs, and the 
quantity and quality of HIV-1-specific immune responses at week 48 on Step 1. 
 
1.1.1 ART initiation prior to HIV-1 antibody detection will be associated with limited or 
no detectable proviral DNA or HIV-1-specific immune responses at week 48 on 
Step 1.  
 
1.1.2 ART initiation in later AHI stages will be associated with larger HIV-1 reservoir 
establishment and quantitatively and qualitatively different HIV-1-specific immune 
responses at week 48 on Step 1. 
 
1.2 
Primary Objective 
 
To compare the amount of cell-associated HIV-1 DNA (CAHD) in 5 million blood-derived 
CD4+ T-cells (assayed by quantitative PCR [qPCR]) at week 48 on Step 1 among 
participants who initiated ART in Fiebig I/II versus Fiebig III/IV versus Fiebig V and had 
sustained suppression of plasma HIV-1 RNA.  
 
1.3 
Secondary Objectives 
 
1.3.1 To evaluate HIV-1-specific CD4+ and CD8+ T-cells by flow cytometry prior to ART 
initiation and while HIV-1 RNA is suppressed on ART: 
a. magnitude and distribution of CD4+ and CD8+ T-cells responses to 
nef/tat/rev/vpr/vpu, gag, pol and env 
b. quality of T-cell responses (i.e., frequency and type of polyfunctional 
responses) 
 
1.3.2 To assess the amount of unspliced HIV-1 RNA in 5 million blood-derived CD4+ T- 
cells prior to ART initiation and while HIV-1 RNA is suppressed on ART. 
 
1.3.3  To assess cell-associated HIV-1 RNA to DNA ratio in participants with quantifiable 
HIV-1 DNA prior to ART initiation and while HIV-1 RNA is suppressed on ART. 
 
1.3.4 To establish a group of well-characterized adults living with HIV who 
initiated ART during AHI that can serve as a source population for future 
ACTG studies, including those designed to test novel interventions to 
achieve HIV remission.  
 


 
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1.4 
Exploratory Objectives  
 
1.4.1 To assess the frequencies of non-transmitted epitope escape mutants prior to 
ART initiation and after 48 weeks of ART on Step 1 by sequencing HIV 
variants, including single genome sequencing and next generation (deep) 
sequencing. 
 
1.4.2 To investigate CAHD in CD4+ T-cells and across subsets (e.g., naïve, central 
memory, effector memory), single copy HIV-1 RNA, and HIV-1-specific immune 
responses in blood; CAHD in gut; and CAHD and single copy HIV-1 RNA in 
cerebrospinal fluid (CSF) at any time on Step 1 from week 60 to week 72 in 
participants who consent and undergo the optional procedures and have 
available data.  
 
1.4.3  To characterize the effects of early ART on innate immune responses during and 
after AHI, including natural killer cell subset frequencies, phenotype, and function 
prior to ART initiation and while HIV-1 RNA is suppressed on ART. 
 
1.4.4 In participants with detectable CAHD at any time point prior to ART initiation and 
while HIV-1 RNA is suppressed on ART, to quantify episomal HIV-1 DNA by 
qPCR for 2-LTR circles and derive the quantity of integrated HIV-1 DNA from the 
total and unintegrated DNA (unintegrated linear DNA or 1-LTR circles would 
have a negligible contribution after 48 weeks of therapy on Step 1). 
 
1.4.5 To investigate the relationship between genetic factors (human leukocyte antigen 
[HLA] typing and CCR5 delta-32 genotyping) and virologic and immunologic 
outcomes prior to ART initiation and while HIV-1 RNA is suppressed on ART. 
  
 
1.4.6 To investigate integration sites prior to ART initiation and while HIV-1 RNA is 
suppressed on ART. 
 
1.4.7 To store samples for future evaluations of HIV-1 reservoirs with novel 
assays, HIV-specific immune responses, viral sequencing, and genetic 
factors.  
 
1.4.8 To characterize the immunologic, virologic, and clinical characteristics of 
AHI, including response to ART. 
 
1.4.9  To evaluate the performance of HIV diagnostic assays during AHI, 
including testing algorithms to distinguish between acute infection, 
chronic infection, and non-infection. 


 
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2.0 
INTRODUCTION 
 
2.1 
Background 
 
Persistent cellular reservoirs of HIV-1 are established very early in AHI [1]. Most proviral 
DNA is in CD4+ T-cells, particularly central and transitional memory T-cells that persist 
through homeostatic, antigen-driven, or other mechanisms of proliferation [2]. Very early 
ART may limit the seeding of cellular reservoirs of HIV-1 [3-5, 6]. Theoretically, ART 
initiated in the earliest Fiebig stages could limit the size and genetic diversity of the HIV-
1 reservoirs, thereby improving the chance of an HIV-1 cure. Paradoxically, however, 
post-treatment controllers in the VISCONTI cohort were mainly those treated in later 
Fiebig stages, i.e., IV-V [7]. There are limited data assessing the impact of the timing of 
ART initiation during AHI on sensitive measures of reservoir size and on virologic and 
immunologic markers of immune control of HIV-1. Several large studies of early ART in 
acute and recent HIV-1 infection such as SPARTAC were designed to evaluate clinical 
outcome and CD4+ T-cells and HIV-1 RNA set point after ART interruption [8]. The 
RV254 Thai study has enrolled mainly Fiebig I to III AHI participants, which limits its 
relevance to later Fiebig stages that are more commonly diagnosed in routine patient 
care. One of the largest studies evaluating residual viremia, proviral DNA and infectious 
virus after early ART had only 27 participants [4]. Although CHAVI has provided detailed 
descriptions of the natural history of immunologic events in acute and early HIV-1 
infection, their studies did not focus on persons treated with modern ART. A thorough 
study is thus needed to define the impact of early ART on virologic and immunologic 
outcomes that are relevant to achieving HIV-1 cure [9]. Current Fiebig staging utilizes 
HIV-1 RNA, p24 antigen, 3rd generation enzyme immunoassay (EIA, IgM-sensitive), 2nd 
generation EIA (IgG-sensitive) and Western blot (WB) to categorize AHI into five stages 
[10].  
 
The duration of these stages varies across individuals and is dependent on the rapidity 
of the HIV-1-specific antibody response. The protocol team hypothesizes that timing of 
ART initiation during different stages of AHI will be predictive of the magnitude and 
characteristics of HIV-1 reservoirs and the quantity and quality of HIV-1-specific immune 
responses. Longitudinal analysis is needed to evaluate the ability of this staging system 
to discern the effects of ART instituted in each study group on HIV-1-specific immune 
responses and HIV reservoirs. 
 
Virologic Outcomes of Interest after Early ART  
As noted above, the impact of early ART on the persistence of HIV-1-infected cells has 
been limited by the number of individuals studied and the detection limits of the assays 
used to detect persistent HIV-1. Assay detection limits can be improved by sampling 
larger numbers of cells for HIV-1 nucleic acid. Accordingly, large numbers of CD4+ T-
cells (5 million) will be assayed for HIV-1 DNA as the primary study endpoint [11]. 
Having no HIV-1 DNA in CD4+ T-cells detected by sensitive methods following ART is 
likely an indication of a limited HIV-1 reservoir that may improve the chance of continued 
virologic control after ART withdrawal. The timing of ART initiation could affect the 
number and location of HIV-1 integration sites, which in turn could affect clonal 
expansion, proviral expression, and responsiveness to anti-latency treatments [12-14]. 


 
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The impact of ART timing on HIV-1 integration sites could be evaluated utilizing samples 
collected during this study. 
 
Immunologic Outcomes of Interest after ART 
The earliest HIV-1-specific T-cell responses are predominantly oligofunctional with 
multifunctional response increasing with time after infection. The epitopes recognized by 
T-cells during AHI may be narrow in range and non-immunodominant. Escape mutations 
can occur early after infection in some individuals and may impact virologic control [15]. 
Early ART, depending on the time of its initiation, may prevent the generation of 
multifunctional T-cell responses [16], but may also preserve HIV-1-specific CD4+ and 
CD8+ T-cell responses [17-22]. These observations were mainly derived from small 
studies of patients whose stage of AHI was not well characterized. In addition, the 
impact of the timing of ART initiation on the frequency of viral immune escape variants is 
undefined, particularly for minor escape variants that can only be detected by single 
genome sequencing or next generation sequencing methods. Immune escape variants 
pose a significant obstacle to immune control of HIV-1; thus identifying the optimal timing 
of ART initiation to prevent their emergence is an exploratory objective of this study. 
 
To achieve sustained virologic control of HIV-1 (ART-free HIV-1 remission) and to clear 
virus expressing cells, it is likely that immune-based therapies will be needed in addition 
to latency-reversing agents, and responses to such therapies may differ depending on 
the pre-existing immune responses to HIV-1. Thus, the optimal strategy for manipulating 
the immune system may be different in infected individuals who initiate ART at different 
Fiebig stages. Defining if and how immune responses persist or evolve over time in 
infected individuals treated during AHI, and how they relate to reservoir size and viral 
diversity, will increase our understanding of critical host-viral interactions and inform the 
development of immune-based therapies for HIV-1 cure.  
 
Tissue HIV-1 Reservoirs 
HIV-1 preferentially persists in the gut mucosa, therefore, larger reservoir sizes in gut 
tissue compared with the peripheral blood are observed even after successful ART [23, 
24]. While early ART is more beneficial than later ART in reducing HIV-1 DNA in gut, 
there are limited data on ART effects on the types of latently infected cells [25-28]. In the 
central nervous system (CNS), CNS inflammation and CSF viremia are reported within 
days following HIV-1 exposure [29]. Latently infected cells and inflammation persist in 
the brain after suppressive ART, but it is not well understood how early ART impacts 
infected cells, low level virus, inflammation, and neuronal injury in the CSF. Failure to 
mount an adequate immune response to control viral replication and eliminate HIV-1-
infected cells in these compartments could directly jeopardize HIV-1 cure.   
 
The Contribution of A5354 to the Understanding of the Effects of Early ART on HIV-1 
Persistence and Immune Responses 
The investigators of this study have engaged investigators of other NIH-funded early 
treatment cohort studies and received enthusiastic response for further cross-study 
collaborations. All groups aim to identify acutely infected individuals and characterize 
their HIV-1 reservoir size after treatment. There are important differences between the 
studies as detailed in Table 2.1-1. Notably, A5354 is unique in its broad inclusion of 


 
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individuals across continents who display different genetic profiles and HIV-1 clades, its 
primary endpoints, and its plans for extended follow-up to facilitate enrollment in 
interventional trials. 
 
The primary endpoint for A5354 is novel. It is the only study that will extensively 
interrogate the HIV-1 reservoir after ART by performing tests to identify CAHD in large 
numbers of CD4+ T-cells. It will secondarily evaluate cell-associated HIV-1 RNA and 
extensively evaluate the HIV-1-specific immune responses to all HIV proteins, providing 
important information that will inform strategies for future immune-based therapies. The 
step-wise approach to performing invasive procedures is innovative and cost-effective.  
Herein, this study will further investigate persistence of HIV-1 in tissues in those 
participants whose peripheral blood yields no detectable HIV-1 DNA. 
 
The RV254 Thai cohort establishes and characterizes an AHI cohort in a high risk 
population. This Division of AIDS (DAIDS)/Department of Defense-funded study 
commenced in 2009 and as of December 2015 has over 300 participants enrolled. The 
study is continuing as an open enrolling cohort with an unlimited sample size. The study 
is conducted at one site in Bangkok with all enrollees being Thai. It has shown so far that 
HIV-1 reservoir size is small when ART is initiated early. The cohort primarily consists of 
Fiebig III followed by Fiebig I individuals, limiting the evaluation of outcomes across all 
Fiebig stages.  
 
The South African cohort, “A Prospective Study of the Virology and Immunology of HIV-1 
Infection in South African Blood Donors: Implementation of ART in Very Early HIV-1 
Infection and Evolution of Elite Controllers” is a National Heart, Lung, and Blood Institute 
funded protocol that is being developed as a collaboration between the University of 
California at San Francisco and the South African National Blood Service (SANBS). The 
acutely infected individuals will be identified within the SANBS catchment areas and 
referred for treatment at study sites.


 
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Table 2.1-1. A5354 and Other NIH-funded Early Treatment Cohort Studies 
Study 
A5354 
RV254 Thai Cohort 
South African Cohort 
Sites 
US and international 
Single site in Bangkok 
5 sites in 4 provinces   
Circulating HIV-1 clades 
Multiple clades represented 
Predominantly CRF01_AE  
Predominantly C 
Number of participants 
196 
≥500 with unlimited numbers 
enrolled 
75  
Primary objectives 
Characterize reservoir/HIV-
specific immunity after early ART 
Cohort of HIV cure research 
candidates 
Characterize reservoir/HIV-specific 
immunity after early ART 
Cohort of HIV cure research 
candidates 
Determine Fiebig stages and 
demonstrate linkage to care for 
acute HIV-1 infected patients 
Measure the size of the reservoir 
after early ART 
Fiebig stages 
Target 50 for each Fiebig I/II, 
Fiebig III/IV, Fiebig V 
Fiebig I to V (~40% F I/II, 50% F III, 
10% F IV/V) 
75 Fiebig I/II 
Identification of acute HIV-
1 infected participants 
Performed routinely at the study 
sites and not part of the protocol 
Screening performed as part of the 
protocol using nucleic acid test 
(NAT) and sequential EIA 
Screening performed as part of 
the protocol using NAT 
Time from enrollment to 
ART initiation 
Same day 
Mean 1 day (range 0-7) 
4 days to 2 weeks 
ART regimens 
EVG/COBI/FTC/TAF and 
BIC/FTC/TAF with some receiving 
locally available alternatives 
TDF/FTC/EFV with some receiving 
RAL and MVC intensification 
TDF/FTC+RAL 
(week 0-24) 
TDF/FTC/EFV 
(week 26-96) 
Virologic assessments 
CAHD in 5 million CD4+ T-cells  
(highest sensitivity) as primary 
endpoint and cell-associated HIV-
1 RNA as secondary endpoint 
DNA and inducible RNA in small 
blood volumes except for 
participants who undergo 
leukapheresis 
DNA and cell-associated RNA in 
small blood volumes except for 
participants who undergo 
leukapheresis 


 
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Study 
A5354 
RV254 Thai Cohort 
South African Cohort 
Immunologic assessments 
Magnitude, distribution, quality of 
T-cell responses to 
nef/tat/rev/vpr/vpu, gag, pol and 
env 
Magnitude and breadth of T-cell 
responses to gag, pol, nef and env 
and other cellular responses (B, 
NK) 
Markers of immune activation 
Clinical CD4+ T-cell 
measurement 
Invasive procedures 
One time after ART: gut biopsy via 
flexible sigmoidoscopy and lumbar 
puncture in a subset of 
participants after 48 weeks of 
ART on Step 1 
Leukapheresis, gut and lymph node 
biopsy, lumbar puncture, genital 
secretion as optional procedures at 
multiple time points before and after 
ART 
Leukapheresis at 3 time points 
after ART 


 
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Acute HIV-1 Infection Identification  
Best effort must be taken to identify and treat persons with AHI. Several strategies may 
be employed with the goal of being able to enroll participants across the study groups 
(Fiebig I/II, III/IV, or V) which include the following: 1) Frequent routine HIV-1 testing of 
high risk patients; 2) Outreach to testing sites and clinic/providers administering pre-
exposure and post-exposure prophylaxis; 3) Performance of HIV-1 testing within one 
week of possible HIV-1 exposure and immediately with any acute retroviral syndrome-
like symptoms; 4) Engagement of sites that have implemented 4th generation enzyme 
immunoassay (EIA) or nucleic acid testing as part of HIV-1 testing as well as outreach to 
testing sites that conduct such tests. 
 
Strategy for Rapid Diagnosis of AHI and Fiebig Staging  
Where practical, we recommend deploying routine screening with 4th generation Ag/Ab 
combo assays (Abbott ARCHITECT HIV-1/2 Combo or Bio-Rad HIV-1/2 Combo or 
Siemens AVIDA Centaur HIV-1/2 Combo) with preference for the Abbott ARCHITECT 
chemiluminescence immunoassay (CMIA) because of the rapid test turn-around-time of 
approximately 30 minutes versus 2 hours for the Bio-Rad; in addition, the broad dynamic 
CMIA range has the potential to use the S/CO to establish HIV-1 infection recency [30]. 
Using an algorithm of a 4th generation Ag/Ab assay in combination with emerging 
technologies for rapid confirmatory and discriminatory HIV-1/2 antibody screening (HIV 
IgG Multispot or the Geenius assay, once available) [31] followed by rapid HIV-1 RNA 
testing using either the laboratory-in-a-tube  (IQuum/Roche) 30-minute quantitative HIV-
1 RNA test or the 60-minute Alere Diagnostics HIV-1/2 RNA assay, it is possible to 
identify participants in Fiebig I/II on the same day as enrollment. 
 
There are currently four Food and Drug Administration (FDA)-approved 4th generation 
HIV-1/2 Ag/Ab screening assay platforms that allow for the diagnosis of acute or 
established HIV-1 infection. All four platforms are able to detect HIV-1 antigen and HIV-
1/2 antibodies in blood serum or plasma. One of these platforms is an EIA (Bio-Rad HIV-
1/2 Combo Ag/Ab EIA); two are a magnetic microparticle-based CMIA (Abbott 
ARCHITECT HIV-1/2 Ag/Ab Combo and Siemens ADVIA Centaur HIV-1/2 Ag/Ab 
Combo assay); and one is a luminex flow-based assay that differentiates HIV-1 antibody 
from HIV-1 p24 antigen and HIV-1 from HIV-2 antibodies (Bio-Rad BioPlex 2200 HIV Ag-
Ab assay). In addition, the recent FDA approval of the confirmatory Bio-Rad Geenius 
HIV-1/2 lateral flow antibody assay offers an opportunity to replace both the rapid 
Multispot HIV-1/2 and the WB with a discriminatory rapid (<30 minutes) antibody 
confirmation of a reactive 4th generation screening test and, in addition, estimates the 
Fiebig stage based on the detection of HIV-1 gag (p24), pol (p31), and env (gp160, 
gp41) antibodies and for HIV-2, two env-specific peptides (gp36 and gp140). The 
available FDA-approved HIV-1 antibody screening and orthogonal confirmatory assays 
are listed in the A5354 Manual of Procedures (MOPS). 
 
The Centers for Disease Control and Prevention (CDC) 4th generation screening 
algorithm may be used to identify acute, early, and established HIV-1 infection (see 
A5354 MOPS). Where available the Geenius assay will be done immediately on site to 
detect or confirm HIV-1 antibody and to allow a preliminary Fiebig staging. Where 


 
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appropriate (e.g., reactive screen and negative antibody assay (e.g., Multispot or 
Geenius), an HIV-1 RNA will be performed at the site.  
 
An analysis of 39,721 specimens tested from a combined research and clinical testing 
service showed that the ARCHITECT S/CO clearly distinguished the false positive 
(0.2%) from AHI (0.1%) and established infection (1.33%) (Figure 2.1-1). Interestingly, 
0.7% of the specimens had a S/CO of between 0.50 and 0.99. Three (10%) of the 30 
AHI had a S/CO of between 0.50 and 0.99, which suggests that in a high-seroincidence 
population, a S/CO less than 1.0 may identify additional AHI [30, 31]. 
 
We posit that the strength of the S/CO will equate with the likelihood of a particular 
infection stage in this high seroincidence study population. 
 
Figure2.1-1. Distribution of ARCHITECT S/CO values:  A, B: non-reactive; C: 
intermediately reactive; D: false-positive; E: acute HIV-1 infection; F: established 
infection [32] 
 
We have shown that the 4th generation ARCHITECT HIV-1/2 Ag/Ab Combo assay in 
comparison to the 4th generation Bio-Rad Combo provides a greater dynamic S/CO 
range for determining recent infection (Figure 2.1-2). The ARCHITECT S/CO was also 
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based on an indeterminate or confirmed WB with or without the presence of HIV-1 p31 
antibody (Figure 2.1-3). However, in conjunciton with the Geenius assay, the Fiebig 
classification can be estimated as I-II (RNA or p24 antigen positive [or both] and no 
antibody) versus III-IV (IgM/IgG with negative or indeterminate WB) versus V (confirmed 
WB and no anti-p31) versus VI (confirmed WB and anti-p31). 
 
Figure 2.1-2. ARCHITECT versus GSCOMBO for S/CO values over the range of HIV-1 
infection [32] 


 
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Figure 2.1-3. ARCHITECT S/CO for HIV-1 infection recency [32] 
 
For the purpose of this study, a S/CO ratio ≥10 is considered “positive” in the 
ARCHITECT assay. However, a S/CO of between 0.5 and 10 that corresponds to HIV-1 
p24 antigen positive AHI represents between 4-5.5 log10 HIV-1 RNA copies/mL [30]. 
Therefore, HIV-1 p24 antigen detection at a S/CO of 0.5 may correspond to 
approximately 6,000 HIV-1 RNA copies/mL (Figure 2.1-4 below), which is well above the 
lower limit of assay detection for commercial assays. Participants with a previous 
ARCHITECT S/CO ratio of <0.5 who now have a value ≥1.0 are eligible to enroll in the 
study pending the HIV-1 RNA determination. Potential participants with S/CO >0.5 but 
<10 will require a positive HIV-1 RNA results prior to enrollment (this criterion will 
decrease the incidence of false-positive HIV-1 infection).  
 
 
 


 
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Figure 2.1-4. The log10 linear relationship between the HIV-1 RNA copies/mL of plasma 
(abscissa) and the ARCHITECT assay S/CO values (ordinate)  
 
Challenges 
The majority (19/23, 83%) of the ACTG international laboratories have an Abbott m2000 
system available, 10/23 (43%) also have the Roche COBAS TM, and most of the 
laboratories conduct HIV-1 RNA testing on-site. However, the turn-around-times (TAT) 
for results is highly variable from <24 hours up to 14 days even for on-site testing. The 
average TAT is 4.6 days and the median is 3 days. These times are independent of 
instrument; i.e., if it takes 2 days for results at one laboratory on the Roche COBAS TM, 
it also takes 2 days for results at the same laboratory using the Abbott m2000 system. 
Inclusion criteria for this study are designed to identify individuals during AHI while 
accommodating differences in testing at various study sites. Fiebig staging will be 
performed using standardized processes at reference laboratories on samples collected 
on the day of study entry. 
 


 
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PCR Assay for Detection of CAHD and Cell-associated RNA in CD4+ T-cells  
A qPCR assay with single-copy sensitivity targeting a highly conserved region of 
integrase in the HIV-1 pol gene [33] will be used to detect HIV-1 DNA or RNA in 5 million 
total CD4+ T-cells.  
 
Antiretroviral Regimen 
The study will provide the open-label EVG/COBI/FTC/TAF or BIC/FTC/TAF to all 
enrolled participants. The availability of these single-tablet regimen (STR) integrase 
strand transfer inhibitor (INSTI)-based regimens will facilitate the rapid initiation of 
therapy and reduction in viral load for those identified with AHI. Single-tablet regimens 
may demonstrate improved adherence and participant satisfaction over multi-pill 
regimens, and INSTI-containing regimens have repeatedly been shown to result in more 
rapid reduction in viral load when compared with non-INSTI-based therapy [34, 35].  
EVG/COBI/FTC/TAF and BIC/FTC/TAF have been approved by the US FDA and both 
include the TAF formulation of tenofovir, which appears to have distinct safety 
advantages over TDF.  
 
TAF is a second generation oral prodrug of tenofovir, a nucleotide analog that when 
phosphorylated inhibits HIV-1 reverse transcriptase. TAF is metabolized to tenofovir 
intracellularly and can be used at a fraction of the dose of TDF with lower blood levels 
and higher intracellular levels. [36] There have been many clinical trials that have 
included TAF as well as EVG/COBI/FTC/TAF, including a phase II study (GS-US-292-
0102) that included 58 participants treated with the regimen with 88.4% having HIV-1 
RNA <50 copies/mL at 48 weeks by snapshot analysis compared with 87.9% in those 
given EVG/COBI/FTC/TDF. Results from the pharmacokinetic study showed that 10 mg 
TAF resulted in lower blood plasma levels of tenofovir than TDF at 300 mg with 
approximately five-fold higher levels of tenofovir diphosphate in peripheral blood 
mononuclear cells (PBMC) than with TDF.  
 
Two phase III registrational trials (GS 104 and GS 111) have been completed and 
published comparing EVG/COBI/FTC/TDF with EVG/COBI/FTC/TAF in a combined 
study of more than 1700 ART-naïve individuals [37]. It is noteworthy that although the 
median CrCl of enrolled participants exceeded 100 mL/minute, the studies did allow for 
enrollment of participants with CrCl ≥50 mL/minute. The proportion with plasma HIV-1 
RNA <50 copies/mL through 48 weeks by snapshot analysis was 90% in the TDF- 
versus 92% in the TAF-containing regimens with adjusted difference of 2.0%, 95% CI -
0.7 to 4.7, meeting pre-specified non-inferiority criteria. Furthermore, there was no 
difference in response in either group based upon baseline plasma HIV-1 RNA (less 
than or equal to or greater than 100,000 copies/mL) or CD4+ T-cell count (less than or 
greater than or equal to 200 cells/µL). Protocol-specified virologic failure (VF) was similar 
and low in both groups as was emergent drug resistance, and the pattern of such 
resistance was similar between study groups. The mean increase in CD4+ T-cell count 
was significantly greater at 48 weeks in the TAF versus TDF group at 230 versus 211 
cells/µL, respectively (p=0.024). The frequency of any AE was 90% in both groups with 
only 1% in each group having drug-related Grade 3 or 4 AEs. Common AEs occurring at 
least in 5% of individuals were also similar between groups with most frequent being 
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on renal function and bone density in these studies since these are recognized AEs 
associated with TDF use. The TAF group had significantly smaller mean serum 
creatinine increases than those given a TDF-based regimen (0.08 versus 0.12 mg/dL, 
p<0.001), less proteinuria (median percent change -3.0 versus 20; p<0.001), and 
significantly smaller decrease in bone mineral density at spine (mean % change -1.3 
versus -2.86; p<0.001) and hip (mean % change -0.66 versus -2.95; p<0.001). There  
was a significantly greater increase in total, LDL and HDL cholesterol as well as 
triglycerides in those receiving a TAF- rather than a TDF-containing regimen, although 
no difference was seen in total cholesterol:HDL ratio. The package insert for 
EVG/COBI/FTC/TAF allows for treatment of participants with CrCl ≥30 mL/minute 
GENVOYA [package insert]. Gilead Sciences, Inc., Foster City, CA; March 2016. 
http://www.gilead.com/~/media/files/pdfs/medicines/hiv/genvoya/ genvoya_ pi.pdf. 
Accessed Mar 30, 2016]. Participants with CrCl <30 mL/minute can be included in the 
study if they are able to access appropriate alternate regimens according to local 
guidelines.  
 
BIC is an HIV-1 INSTI. It has shown synergistic effects when combined with other 
ARVs including TAF and FTC. It has a median half-life of 15.9 to 20.9 hours [38, 
39], and is cleared equally through UGT1A1 glucuronidation and CYP3A4 
oxidation. BIC has a superior resistance profile compared to some of the other 
currently approved drugs in the same class. It is potent against a panel of patient-
derived HIV-1 isolates with high-level INSTI resistance. A 10-day dose ranging 
study of BIC monotherapy showed anti-viral effects in both ARV-naïve and ARV-
experienced (INSTI-naïve) people [40]. A randomized, double-blind, placebo 
controlled Phase II study compared BIC 75mg/FTC 200mg/TAF 25 mg (n=65) 
versus DTG 50mg/FTC 200mg/TAF 25mg (n=33) in ARV-naïve adults. At week 24, 
63 of 65 (96.9%) in BIC group versus 31 of 33 (93.9%) in DTG group had HIV RNA < 
50 copies/ml. Adverse events were reported in 85% in the BIC group versus 67% 
in the DTG group. Most common AEs were diarrhea and nausea.  One participant 
in the BIC group discontinued due to urticarial reaction. No SAEs or deaths 
occurred [41]. A Phase III randomized, controlled, clinical trial of BIC/FTC/TAF 
versus DTG/FTC/TAF in ARV-naïve adults showed the former was non-inferior to 
the latter for virological suppression. There was no treatment-emergent 
resistance. BIC/FTC/TAF was safe and showed less reduction in eGFR compared 
to DTG/FTC/TAF. There were no discontinuations due to renal side effects, and 
changes in lipid parameters were similar between arms (NCT02607956). An 
ongoing Phase III study comparing the STR of BIC/FTC/TAF (n=314) with 
DTG/ABC/3TC (n=315) in treatment-naïve adults showed similar viral suppression 
< 50 copies/mL at week 48: 92.4% with BIC/FTC/TAF versus 93% with 
DTG/ABC/3TC. The discontinuation rates were similar between arms: 6% versus 
5%, respectively. Most common side effects in the BIC versus DTG arms were 
diarrhea (12.7% versus 13%), headache (11.5% versus 13.7%) and nausea (10.2 
versus 22.9%) (NCT02607930). There are four ongoing Phase III switch studies, 
with three evaluating safety and effectiveness of the switch to BIC/FTC/TAF from 
any suppressive ARV regimen (NCT02603120, NCT02652624, and NCT02603107). 
The fourth study (NCT03110380) will perform similar evaluations but with a switch 
to BIC/FTC/TAF from regimens with DTG and either FTC/TDF or FTC/TAF.  


 
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Urgency of ART Initiation 
Results of the Strategic Timing of Antiretroviral Treatment (START) study highlight the 
clinical benefits of initiating ART soon after HIV-1 diagnosis, regardless of CD4+ T-cell 
count [42]. Randomization into early and deferred treatment arms was halted in May 
2015, after a scheduled interim review of study data by the Data and Safety Monitoring 
Board. Over an average follow-up of 3 years, the risk of AIDS, other serious illnesses or 
death was reduced by 57% among those in the early treatment group compared with 
those in the deferred treatment group. The study authors reported 42 instances of AIDS, 
serious non-AIDS illness, or death among those enrolled in the study’s early treatment 
group compared with 96 such events in the deferred treatment group. Similar results 
were seen in the TEMPRANO study; immediate ART initiation reduced the incidence of 
death or severe HIV-related illness by 44% as compared with delayed initiation of ART 
after CD4+ T-cell count dropped below 500 cells/mm3 [43]. These results have impacted 
treatment guidelines to favor universal treatment of HIV infection as soon as it is 
diagnosed. 
 
There is a particular urgency to initiate ART during the first few weeks of infection, as 
this may limit the establishment of HIV latency [3-6]. Seeding of the latent HIV reservoir 
begins very early in AHI and the reservoir increases in size as individuals progress 
through the Fiebig stages [2, 5]. Fiebig I-IV stages are each projected to last an average 
of only about 3-5 days and some individuals may progress even more rapidly [10]. 
Investigators anticipate that individuals who have a high-risk for incident HIV-1 infection 
will be referred for possible enrollment in this protocol upon receipt of laboratory results 
suggesting recent HIV-1 infection. It is critical that these potential participants be 
screened for study entry and enrolled into the protocol before they advance in their 
Fiebig staging. Urgent enrollment and immediate initiation of ART is necessary in order 
to limit establishment of the latent HIV-1 reservoir and, in this study, to ensure that 
enrollment includes participants who initiated ART during the very earliest Fiebig stages. 
 
For these reasons, consenting individuals who satisfy criteria for enrollment into this 
study will begin ART on the day of study entry. HIV-1 RNA testing will also be performed 
at the time of study entry. ART initiation will not be delayed while awaiting results of HIV-
1 tests in participants with high likelihood of having AHI based on inclusion criteria. 
Results of entry HIV-1 testing will generally be made available within 72 hours.  
There is a theoretical possibility that participants will be enrolled but are later discovered 
not to be infected with HIV-1. Enrollment criteria defined by signal-to-cutoff ratio 
(S/CO) of 4th generation EIA do not all include confirmatory HIV-1 testing, but have 
been shown to have a positive predictive value of nearly 100% [Bob Coombs, personal 
communication]. In rare cases in which individuals are started on ART and later found 
not to be infected with HIV-1, these individuals will typically receive three or fewer doses 
of ART while awaiting the results of HIV-1 RNA testing, which will generally be made 
available within 72 hours of study entry. ART will be stopped as soon as the negative 
HIV-1 test result is reported. The safety of ART has been well-documented in HIV-1-
uninfected individuals who receive ART for both pre-exposure and post-exposure 
prophylaxis [44-49]. The brief ART exposure that is a potential, but unlikely, outcome of 
ART initiation upon study entry is expected to be safe and well-tolerated.  
 


 
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Feasibility of A5354 Enrollment 
The ACTG site survey (conducted in late 2014) has illustrated marked enthusiasm and 
feasibility for enrolling this study within DAIDS networks. Of 43 sites that completed the 
survey, 63% actively screen for AHI, 78% of sites routinely perform 4th generation EIA 
for HIV diagnostics, and 60% perform NAT on antibody negative samples. In addition, 
84% of sites confirmed the capability to identify and initiate ART in acutely infected 
participants. Capabilities for performing invasive procedures were high with percentages 
of sites able to perform each procedure as follows: 75% for leukapheresis, 92% for gut 
biopsy, 83% for lymph node biopsy, 97% for lumbar puncture, and 97% for genital 
secretion collection. These sites are located in the US and internationally (Thailand, 
Kenya, South Africa, and Peru). Specifically, there were 18 sites (6 domestic and 12 
international) that estimated enrollment of at least 10 acutely infected individuals per 
year and can also perform at least one invasive procedure.   
 
We intend to enroll individuals at ACTG sites with experience treating and following HIV-
1-infected individuals. Sites will be selected based on the following criteria: 1) actively 
screen for AHI, 2) track record of identifying acutely infected individuals, 3) demonstrate 
high retention and viral suppression rates on ART in previous studies, and 4) are 
capable of performing large volume blood draw or the optional leukapheresis.  
 
The study team is confident that it will be feasible to enroll 196 participants in a 36-
month period. As of May 22, 2019, 202 individuals have been screened for 
enrollment into the study and 168 participants have been enrolled. Group 1 
remains open to accrual and is nearing its target enrollment. Groups 2 and 3 have 
been fully accrued under protocol Version 1.0. 
 
Inclusion of Pregnant and Breastfeeding Women 
The inclusion of pregnant women in this study helps maintain the feasibility of enrolling 
an adequate number of female participants in order to achieve overall enrollment goals. 
A new diagnosis of pregnancy indicates recent unprotected sexual activity that, 
particularly in high-risk populations, may lead to HIV-1 acquisition. During pregnancy, 
immunological and hormonal changes affect the mucosa of the genital tract and increase 
the risk of HIV-1 acquisition [50, 51]. Previous studies have demonstrated higher rates of 
HIV-1 seroconversion among pregnant women than among non-pregnant peers [51-54]. 
The ongoing RV217 cohort study that screens HIV-negative participants at high risk for 
HIV-1 infection twice weekly to capture AHI observed 25 of the first 48 female 
participants to be pregnant at some point during the study [Merlin Robb, personal 
communication]. Both the US Department of Health and Human Services (DHHS) adult 
and adolescent HIV treatment guidelines and the perinatal HIV treatment guidelines 
recommend the initiation of ART in all pregnant women with acute or recent HIV-1 
infection as soon as possible in order to maximally reduce plasma HIV-1 RNA, both to 
improve maternal health and prevent perinatal transmission of HIV-1 (AI strength of 
recommendation) [55, 56]. Pregnant participants will not be eligible to volunteer for 
optional invasive procedures. Blood volumes collected from pregnant participants will be 
carefully monitored and will be adjusted as needed to maintain the safety of the 
participant. Breastfeeding practice is common in many countries where the study sites 
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of HIV-1 during breastfeeding in women with AHI; therefore, this protocol recommends 
ART initiation in all HIV-1-infected pregnant and breastfeeding women. Because there 
are limited data on the safety of EVG/COBI/FTC/TAF and BIC/FTC/TAF in pregnant and 
breastfeeding women, this protocol recommends that study sites secure alternative 
regimens according to local guidelines for these women until they are no longer 
pregnant or breastfeeding, at which time, they have the options to stay on the same 
regimen or use the regimen provided by this study. 
 
Extended Follow-up Period for All Study Groups Enrolled into Step 2 
Enrollment into the extended follow-up period (Step 2) for all study groups will 
require that participants have maintained virologic suppression while on study 
(i.e., no virologic failure per protocol definition) and have not discontinued from 
the study for other reasons through week 72. As of the May 22, 2019 monitoring 
report, we estimated that 74% of participants will qualify for the extended Step 2 
follow-up period. The team’s intention is to have these participants continue on 
study for an additional 3 years (after the final Step 1 visit at week 72) with the 
extended follow-up visits occurring every 24 weeks until 144 weeks after entry to 
Step 2. Step 2 will involve limited evaluations, and there will be no invasive 
procedures. We expect that safety laboratory testing will be done according to 
standard of care outside of the protocol and no less than every 6 months. 
 
Inclusion of Re-enrolled Participants from A5354 Version 1.0 into Step 2 
Group 1, 2, and 3 participants who completed the study at week 72 and went off 
study under protocol Version 1.0 will be allowed to re-enroll if they have 
maintained virologic suppression and meet the Step 2 eligibility criteria. The “re-
enrolled” participants will be placed in the Fiebig group in which they were 
initially enrolled in under protocol Version 1.0 and will be followed per the Step 2 
schedule.  
 
The rationale for the extended follow-up period is to expand the number of 
available participants for future therapeutic and cure studies without the burden 
of frequent visits and the cost of study-provided laboratory testing. 
 
2.2 
Rationale 
 
The study-provided regimen is STR EVG/COBI/FTC/TAF or BIC/FTC/TAF. Other non-
study-provided ARV regimens will be allowed for participants who are pregnant, 
breastfeeding, or unable/unwilling to take EVG/COBI/FTC/TAF or BIC/FTC/TAF, or for 
participants whose local health care/primary care provider prefers starting a different 
initial ARV regimen.  
 
This study aims to understand the extent of HIV-1 reservoir establishment and HIV-1- 
specific immune responses across stages of AHI before and after suppressive ART in 
the context of diverse HIV-1 clades. Such insight will be critical in designing therapeutic 
strategies and understanding the responses observed to future interventions in cure-
related studies. The study will also provide a well-characterized and virologically 
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as they emerge. The primary rationale for conducting this study is to achieve the 
following goals: 
1. Design a study to leverage existing infrastructure, resources, and expertise across 
DAIDS networks to determine the effect of ART initiated during different stages of 
AHI on HIV-1 persistence and HIV-1-specific immune responses. 
2. Make ART available through this study to eligible individuals to initiate ART within a 
very short time of being diagnosed with AHI. 
3. Accumulate a cohort of well-characterized participants who initiated ART during 
different stages of AHI with expected differences in HIV-1 reservoirs and HIV-1-
specific immune responses and who will be well-suited for studies of curative 
interventions. 
 
3.0 
STUDY DESIGN 
 
This is a Phase II, prospective, open-label two-step study to measure the effects of 
early ART on the establishment of HIV-1 reservoir and HIV-1-specific immunity. 
Participants will be enrolled if they fulfill the inclusion criteria for AHI diagnosis within 7 
days prior to entry and will have an enrollment visit with the immediate initiation of ART. 
Plasma and serum samples for Fiebig staging will be collected at the time of ART 
initiation.  
 
Participants will be followed for up to 216 weeks in Steps 1 and 2. Evaluations at weeks 
2 and 8 on Step 1 will be performed via telephone. The primary endpoint is CAHD in 5 
million blood-derived CD4+ T-cells assayed by qPCR at week 48 on Step 1.  
 
A subset of eligible participants in Groups 1, 2, and 3 who have completed week 48 
on Step 1 will be consented for CSF collection via lumbar puncture and/or gut biopsy 
via flexible sigmoidoscopy. A target of 25 participants are estimated to have each of 
the aforementioned optional procedure. These procedures are optional and 
participants may consent to one or both of them, which will be performed at any time 
from week 60 to week 72 on Step 1.  
 
The Fiebig stage-classification system will be used to characterize the progression from 
HIV-1 exposure to HIV-1 seroconversion at the time of ART initiation. Samples of 
plasma and serum will be collected at the time of ART initiation, and the results of the 
Fiebig stage at ART initiation will be available within 12 weeks following entry to Step 
1. In this study, the five Fiebig stages of interest will be simplified into three study groups 
as described below (based on HIV-1 antibody diagnostic profile at time of ART 
initiation). 
Group 1: Fiebig I/II (non-reactive HIV-1 antibody) 
Group 2:  Fiebig III/IV (reactive HIV-1 antibody and negative or indeterminate results on 
the WB or Geenius HIV-1/HIV-2) (This study group is closed to enrollment 
under protocol Version 1.0.) 
Group 3: Fiebig V (reactive HIV-1 antibody and positive WB or Geenius HIV-1/HIV-2 
without p31 band) (This study group is closed to enrollment under 
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Each study group had a target enrollment of 50 participants under protocol 
Version 1.0. Study Groups 2 and 3 reached their target enrollment under protocol 
Version 1.0; therefore, the original inclusion criteria from protocol Version 1.0 
corresponding to these groups are no longer applicable for eligibility into the 
study. Participants who meet criteria for enrollment and are found to be in Group 
2 or 3 based upon Fiebig staging at time of ART initiation will be followed in those 
groups per protocol. Participants who are enrolled in Groups 1, 2, and 3 will 
complete Step 1 of the study at week 72, and willing participants who have 
completed Step 1 follow-up without meeting the criteria for study discontinuation 
(refer to section 9.2) will be encouraged to continue on Step 2 and complete study 
evaluations through 144 weeks of Step 2 follow-up. For those participants who 
completed the week 72 visit under protocol Version 1.0 and meet eligibility criteria 
for re-enrollment into Step 2, they will remain on Step 2 for up to 144 weeks of 
follow-up. 
 
Although participants in Fiebig VI (positive WB or Geenius HIV-1/HIV-2 with p31 
band) are not specifically targeted for enrollment in this study, it is possible that a 
small number of participants will be determined to be in Fiebig VI based on 
analysis of the entry samples and will be followed on the study for no more than 
24 weeks on Step 1. In order to provide time to ensure a smooth transition off of the 
study without compromising the continuity of ART, participants who are determined to be 
in Fiebig VI (based on centralized testing) will be followed on study for no more than 
24 weeks on Step 1 allowing ample time for them to pursue alternative sources for 
ART. Confirmed Fiebig VI and HIV negative participants will be replaced.  
 
NOTE: The CMC will review the Fiebig stage determination outcome and will ensure that 
these results are communicated to the sites (refer to details in A5354 MOPS). 
 
The study-provided regimen is STR EVG/COBI/FTC/TAF or BIC/FTC/TAF. 
EVG/COBI/FTC/TAF and BIC/FTC/TAF are being provided for the following reasons: 1) 
rapid decline in viremia and potential to reduce reservoir seeding with INSTI, 2) 
generally low frequencies of transmitted INSTI resistance, 3) potentially improved 
adherence with STRs, and 4) the TAF formulation may have fewer renal and bone 
adverse effect than TDF. Other non-study-provided ARV regimens will also be allowed 
for participants are pregnant, breastfeeding, or unable/unwilling to take 
EVG/COBI/FTC/TAF or BIC/FTC/TAF, or for participants whose local health 
care/primary care provider prefers starting a different initial ARV regimen. Investigators 
may choose an appropriate non-study-provided ARV regimen for any of these reasons. 
Alternative regimens will not be provided by the study, but their use does not preclude 
participation in the study. This flexibility is expected to enhance enrollment and 
adherence to the study requirements. Use of alternative regimens other than 
EVG/COBI/FTC/TAF or BIC/FTC/TAF must not delay the initiation of ART. 
 


 
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4.0 
SELECTION AND ENROLLMENT OF PARTICIPANTS 
 
4.1 
Step 1 Inclusion Criteria for Group 1 
 
4.1.1 Appropriate documentation from medical records of diagnosis of AHI within 7 
days prior to enrollment, that includes one of the following:  
 
a) A detectable HIV-1 RNA within 28 days prior to study entry AND a non-
reactive HIV-1 antibody within 7 days prior to entry  
OR  
b) ARCHITECT or GSCOMBO S/CO ≥10 within 7 days prior to entry AND a 
non-reactive HIV-1 antibody within 7 days prior to entry  
OR 
c) ARCHITECT or GSCOMBO S/CO ≥1 within 7 days prior to entry AND a non-
reactive HIV-1 antibody within 7 days prior to entry AND a known prior S/CO 
<0.5 within 90 days prior to entry  
OR 
d) ARCHITECT or GSCOMBO S/CO >0.5 but <10 within 7 days prior to entry 
AND a non-reactive HIV-1 antibody within 7 days prior to entry AND 
detectable HIV-1 RNA within 7 days prior to entry  
 
NOTE A: HIV-1 RNA result must be reported from an FDA-approved or CE-
marked assay.  
NOTE B: Refer to section 10.5 for additional information on estimated Fiebig 
group according to each inclusion criterion above. The protocol team 
will notify the sites if some criteria may no longer be used because 
accrual is completed in certain Fiebig groups.  
NOTE C:  Specimens for the testing specified in section 4.1.1 above may be 
collected on the day of study entry provided the testing result is 
available prior to enrollment.  
 
4.1.2 Men and women age ≥18 years. 
 
4.1.3 Ability and willingness of candidate to provide written informed consent. 
 
4.1.4 Ability and willingness to initiate ART at enrollment. 
 
4.1.5 Ability and willingness to participate in scheduled study visits per the schedule 
of events (SOE).   
 
4.1.6 Female candidates of reproductive potential who are not pregnant at the time of 
enrollment and who will receive the study-provided EVG/COBI/FTC/TAF or 
BIC/FTC/TAF must agree not to participate in the conception process (i.e., active 
attempt to become pregnant, in vitro fertilization), and if participating in sexual 
activity that could lead to pregnancy, the female candidate must agree to use at 
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Female candidates are considered to be of reproductive potential if all of the 
following conditions apply: 
• 
Candidate has experienced menarche. 
• 
Candidate has not undergone bilateral tubal ligation, bilateral oophorectomy, 
or hysterectomy. 
• 
Candidate has not experienced menopause, defined as lack of menstruation 
within the preceding 12 months. 
 
Acceptable contraceptive methods include: 
• 
Condoms (male or female) with or without a spermicidal agent 
• 
Diaphragm or cervical cap with spermicide 
• 
Intrauterine device  
• 
Hormonal contraceptive 
 
Female candidates who are not of reproductive potential or whose male 
partner(s) has documented azoospermia are not required to use contraceptives. 
Any statement of self-reported sterility or that of her partner must be entered in 
the source documents.   
 
NOTE: Acceptable documentation of lack of reproductive potential is oral or 
written documentation from the individual. 
 
4.1.7 Pregnant and breastfeeding women who agree to initiate a non-study-
provided ARV regimen per section 8.9, and who otherwise meet the 
eligibility requirements. 
 
NOTE: Female candidates who are prescribed a non-study-provided ARV 
regimen should discuss the safety of that regimen during conception and 
pregnancy with the prescribing physician. Such individuals should follow medical 
guidance regarding any potential need for contraception while using the non-
study-provided ARV regimen.  
 
4.2 
Step 1 Exclusion Criteria for Group 1  
 
4.2.1 Positive HIV-1 antibody test ≥90 days prior to study entry.  
 
4.2.2 Active drug or alcohol use or dependence that, in the opinion of the site 
investigator, would interfere with adherence to study requirements. 
 
4.2.3 Any acute, chronic, or recent and clinically significant medical condition that, in 
the opinion of the site investigator, would interfere with adherence to study 
requirements or jeopardize the safety or rights of the participant.  
 
4.2.4 Receipt of an investigational study agent within 28 days prior to enrollment. 
 


 
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4.2.5 Chronic or recurrent use of medications that modify the host immune response, 
e.g., oral or parenteral steroids, cancer chemotherapy. 
 
4.2.6 AHI diagnosis within 60 days prior to study entry after receiving any 
investigational ARV or HIV-1 vaccine or immune prophylaxis for HIV-1 infection. 
 
4.2.7 Use of ARVs for any reason, including pre- or post-exposure prophylaxis within 
60 days prior to study entry. 
 
4.3 
Step 2 Inclusion Criteria  
 
NOTE: Below inclusion criteria apply to the following groups of participants: 
• 
Participants transitioning directly from Step 1 to Step 2 as part of 
A5354 Version 2.0.  
OR 
• 
Participants enrolling to Step 2 after having previously completed the 
week 72 visit and who went off study under A5354 Version 1.0. 
 
4.3.1 Most recent HIV-1 RNA <50 copies/mL obtained within 90 days prior to Step 
2 entry.  
 
4.3.2 Completed 72 weeks of follow-up on Step 1. 
 
NOTE: Participants who discontinued A5354 following a full 72 weeks of 
follow-up on Step 1 may enroll to Step 2 regardless of time spent off-study, 
given they meet other eligibility criteria. 
 
4.3.3 Ability and willingness of candidate to provide written informed consent 
that includes Step 2. 
 
4.3.4 Ability and willingness to continue ART.  
 
NOTE: Switching to the study-provided ARV or staying on the current ARV 
regimen prior to Step 2 entry is permitted.  
 
4.3.5 Ability and willingness to participate in scheduled study visits per SOE.   
 
4.3.6 Female candidates of reproductive potential who are not pregnant at the 
time of Step 2 enrollment and who will receive the study-provided 
EVG/COBI/FTC/TAF or BIC/FTC/TAF must agree not to participate in the 
conception process (i.e., active attempt to become pregnant, in vitro 
fertilization), and if participating in sexual activity that could lead to 
pregnancy, the female candidate must agree to use at least one reliable 
form of contraceptive while receiving study-provided treatment. 
 


 
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Female candidates are considered to be of reproductive potential if all of 
the following conditions apply: 
• 
Candidate has experienced menarche. 
• 
Candidate has not undergone bilateral tubal ligation, bilateral 
oophorectomy, or hysterectomy. 
• 
Candidate has not experienced menopause, defined as lack of 
menstruation within the preceding 12 months. 
 
Acceptable contraceptive methods include: 
• 
Condoms (male or female) with or without a spermicidal agent 
• 
Diaphragm or cervical cap with spermicide 
• 
Intrauterine device  
• 
Hormonal contraceptive 
 
Female candidates who are not of reproductive potential or whose male 
partner(s) has documented azoospermia are not required to use 
contraceptives. Any statement of self-reported sterility or that of her 
partner must be entered in the source documents.   
 
NOTE: Acceptable documentation of lack of reproductive potential is oral 
or written documentation from the individual. 
 
4.3.7 Women who are pregnant at the time of enrollment into Step 2 and agree to 
use a non-study-provided ARV regimen per section 8.9, and who otherwise 
meet requirements are eligible. 
 
NOTE: Female candidates who are prescribed a non-study-provided ARV 
regimen should discuss the safety of that regimen during conception and 
pregnancy with the prescribing physician. Such individuals should follow 
medical guidance regarding any potential need for contraception while 
using the non-study-provided ARV regimen.  
 
4.4  
Step 2 Exclusion Criteria  
 
NOTE: Below exclusion criteria apply to the following groups of participants: 
• 
Participants transitioning directly from Step 1 to Step 2 as part of 
A5354 Version 2.0.  
OR 
• 
Participants enrolling to Step 2 after having previously completed the 
week 72 visit and who went off study under A5354 Version 1.0. 
 
4.4.1  ARV interruption for greater than or equal to 7 consecutive days at any 
time after ART initiation and prior to entry into Step 2, including while on 
Step 1 or after completion of Step 1. 
 


 
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4.4.2  Protocol-defined virologic failure (section 6.3.4) at any time prior to entry 
into Step 2, including while on Step 1 or after completion of Step 1.  
 
4.4.3 Active drug or alcohol use or dependence that, in the opinion of the site 
investigator, would interfere with adherence to study requirements. 
 
4.4.4 Any acute, chronic, or recent and clinically significant medical condition 
that, in the opinion of the site investigator, would interfere with adherence 
to study requirements or jeopardize the safety or rights of the participant.  
 
4.4.5 Receipt of any investigational study agent since entry to Step 1.  
 
4.4.6 Chronic or recurrent use of medications that modify the host immune 
response (e.g., oral or parenteral steroids, cancer chemotherapy, 
biologics). 
 
4.5 
Study Enrollment Procedures 
 
4.5.1  Prior to implementation of this protocol, and any subsequent full version 
amendments, each site must have the protocol and the protocol consent form 
approved, as appropriate, by their local institutional review board (IRB)/Ethics 
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 approval(s) 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 the required documents have been received. Site-specific ICF(s) 
WILL NOT be reviewed and approved by the DAIDS PRO and 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. 
 


 
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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 
(https://rsc.niaid.nih.gov/clinical-research-sites/daids-protocol-registration-
policy-and-procedures-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.  
 
Participants from whom a signed informed consent has been obtained may 
be screened and enrolled, if they otherwise qualify. An ACTG Screening 
Checklist must be entered through the DMC Participant Enrollment System.  
 
4.5.2 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 of participants for enrollment.  
4.5.3 Participant Registration 
 
For candidates 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.   
 
4.6  
Coenrollment Guidelines  
 
• 
US sites are encouraged to coenroll participants in A5128, “Plan for Obtaining 
Informed Consent to Use Stored Human Biological Materials (HBM) for Currently 
Unspecified Analyses.”  
• 
Non-US sites are encouraged to coenroll participants in A5243, “Plan for Obtaining 
Human Biological Samples at Non-US Clinical Research Sites for Currently 
Unspecified Genetic Analyses.” 
• 
Coenrollment in A5128 or A5243 does not require permission from the A5354 
protocol chairs.  
• 
For specific questions and approval for coenrollment in other studies, sites should 
contact the protocol team via e-mail as described in the Study Management section. 
 


 
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5.0 
STUDY TREATMENT  
 
5.1 
Regimens, Administration, and Duration 
 
Study treatment is defined as STR elvitegravir/cobicistat/emtricitabine/tenofovir 
alafenamide (EVG/COBI/FTC/TAF) or bictegravir/emtricitabine/tenofovir 
alafenamide (BIC/FTC/TAF), which will be provided through the study.  
 
NOTE: Switching of ARV regimen is allowed (i.e., from EVG/COBI/FTC/TAF to 
BIC/FTC/TAF, or vice versa, or to an alternate non-study-provided ART) without 
consulting the CMC.   
 
5.1.1 Regimen 
 
Participants will receive elvitegravir 150 mg/cobicistat 150 mg/emtricitabine 
200mg/tenofovir alafenamide 10mg (EVG/COBI/FTC/TAF) or bictegravir 
50mg/emtricitabine 200 mg/tenofovir alafenamide 25 mg (BIC/FTC/TAF).  
 
NOTE: Other non-study-provided ARV regimens will be allowed for participants 
who are pregnant, breastfeeding, or unable/unwilling to take 
EVG/COBI/FTC/TAF or BIC/FTC/TAF, or for participants whose local health 
care/primary care provider prefers starting a different initial ARV regimen. 
 
5.1.2  Administration 
 
EVG/COBI/FTC/TAF (with food) or BIC/FTC/TAF (with or without food) will be 
administered as one tablet by mouth daily. 
 
5.1.3  Duration 
 
On Step 1, participants will take study medications for up to 72 weeks. 
 
On Step 2, participants will take study medications for up to 144 weeks. 
 
5.2 
Study Product Formulation and Preparation 
 
EVG/COBI/FTC/TAF and BIC/FTC/TAF tablets. Store at 25°C (77°F); excursions 
permitted from 15-30°C (59°-86°F); USP Controlled Room Temperature.  
 
5.3 
Pharmacy: Product Supply, Distribution, and Accountability 
 
5.3.1 Study Product Supply/Distribution 
 
EVG/COBI/FTC/TAF and BIC/FTC/TAF will be supplied by Gilead.  
 
EVG/COBI/FTC/TAF and BIC/FTC/TAF will be available through the NIAID 
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should obtain the study product(s) for this protocol by following the instructions in 
the manual Pharmacy Guidelines and Instructions for DAIDS Clinical Trials 
Networks.  
 
Any study product not provided by the study must comply with the NIAID 
(DAIDS) policy that outlines the process for authorizing the use of study products 
not marketed in the US in NIAID (DAIDS)-supported and/or -sponsored clinical 
trials. This policy is available on the NIAID (DAIDS) website at 
https://www.niaid.nih.gov/sites/default/files/NonFDAapprovedProducts.pdf. 
 
5.3.2 Study Product Accountability 
 
The site pharmacist is required to maintain complete records of all study products 
received from the NIAID CRPMC and subsequently dispensed. At US CRSs, all 
unused study products must be returned to the NIAID CRPMC (or as otherwise 
directed by the sponsor) after the study is completed or terminated. The 
procedures to be followed are provided in the manual Pharmacy Guidelines and 
Instructions for DAIDS Clinical Trials Networks. At non-US CRSs, the site 
pharmacist must follow the instructions in the Pharmacy Guidelines and 
Instructions for DAIDS Clinical Trials Networks for the destruction of unused 
study products. 
 
5.4 
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 updated ACTG Drug Interactions 
Database located at http://tprc.pharm.buffalo.edu/home/di_search/. 
 
5.4.1 Required Medications 
 
Participants must be on a combination ARV regimen. The study-provided 
regimen will be STR EVG/COBI/FTC/TAF or BIC/FTC/TAF. EVG/COBI/FTC/TAF 
or BIC/FTC/TAF, but alternative regimens are allowed based on clinical 
indication or participant preference (section 5.1.1). Switching of ARV regimens 
is allowed (e.g., from EVG/COBI/FTC/TAF to BIC/FTC/TAF or to an alternate 
non-study-provided ART) without consulting the CMC.  
 
 


 
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5.4.2 Prohibited Medications 
 
Table 5.4.2-1:  Prohibited Medications for EVG/COBI/FTC/TAF 
Medication/Drug Class 
Prohibited Medication 
Anti-infectives 
Any anti-HIV combination drugs containing FTC or lamivudine such 
as 
• 
Atripla (efavirenz, emtricitabine, and tenofovir); 
• 
Combivir (lamivudine and zidovudine); 
• 
Complera (rilpivirine, emtricitabine, and tenofovir); 
• 
Epivir (lamivudine); 
• 
Epzicom (abacavir and lamivudine); 
• 
Stribild (cobicistat, elvitegravir, emtricitabine, and tenofovir); 
• 
Trizivir (abacavir, lamivudine, and zidovudine); and 
• 
Truvada (emtricitabine and tenofovir). 
Concomitant use with Tybost and atazanavir or darunavir AND any of the following drugs 
listed below: 
Alpha 1-Adrenoreceptor 
Antagonist 
• 
Alfuzosin 
Antiarrhythmic 
• 
Dronedarone 
Anti-bacterial 
• 
Rifamycins (rifampin, rifabutin, rifapentine) 
Anti-infectives 
Any anti-HIV drugs containing tenofovir:   
• 
Atripla; 
• 
Complera; 
• 
Descovy 
• 
Odefsey 
• 
Stribild; and  
• 
Symtuza 
• 
Truvada 
In combination with HEPSERA 
Antimicrobial 
• 
Rifampin 
Antineoplastics 
• 
Irinotecan 
Ergot Derivatives 
• 
Dihydroergotamine, 
Ergotamine, 
Methylergonovine 
GI Motility Agent 
• 
Cisapride 
Herbal Products 
• 
St. John's wort  
(Hypericum perforatum) 
HMG-CoA Reductase 
Inhibitors 
• 
Lovastatin, 
Simvastatin 
Nephrotoxic drugs 
• 
Cidofovir 
• 
Hepsera (adefovir) 
Non-nucleoside Reverse 
Transcriptase Inhibitor 
• 
Nevirapine 
Phosphodiesterase-5 
• 
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Medication/Drug Class 
Prohibited Medication 
(PDE5) Inhibitor 
pulmonary arterial hypertension 
Protease Inhibitor 
• 
Indinavir 
Sedative/Hypnotics 
• 
Triazolam, chronic oral midazolam (one oral dose permitted) 
Due to the need to use Vitekta with a protease inhibitor coadministered with ritonavir, consult 
prescribing information of coadministered protease inhibitor and ritonavir for their 
contraindications. 
Anti-infectives 
• 
Any anti-HIV drugs containing elvitegravir:   
• 
Stribild 
 
 
Table 5.4.2-2: Prohibited Medications for BIC/FTC/TAF 
Medication/Drug Class 
Prohibited Medication 
Antiarrhythmic Agent 
Dofetilide 
Anticonvulsants 
• 
carbamazepine 
• 
oxcarbazepine 
• 
phenobarbital 
• 
phenytoin 
Antimycobacterials 
• 
rifabutin 
• 
rifampin 
• 
rifapentine 
Antiretrovirals 
• 
Any antiretroviral drug 
that is not part of the 
study regimen 
Herbal/Natural 
Supplements 
• 
St. John’s Wort 
 
5.4.3 Precautionary Medications 
 
Package inserts or investigator brochures for ARV drugs and concomitant 
agents and updated information from the DAIDS should be consulted 
whenever a concomitant medication is initiated or a dose is changed. 
Additional drug information may be found in the ACTG Drug Interaction 
Database on the ACTG website at: https://actgnetwork.org/ACTG-Drug-
Interactions-Database. 
 
Table 5.4.3-1: Precautionary Medications for EVG/COBI/FTC/TAF 
 
• 
Take caution when used in patients with known risk factors for liver diseases 
and impaired renal function. 
• 
Reduction of the dosage of Emtriva is recommended for patients with impaired 
renal function. 
• 
Take caution when used in patients at risk for renal dysfunction and/or who 
have new onset or worsening renal impairment.  


 
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• 
Take caution when used in combination with a protease inhibitor and 
cobicistat. 
Anticoagulants 
Antifungals 
Anti-inflammatory 
Colchicine 
Rivaroxaban 
Voriconazole 
• 
Take caution when used in patients with medical conditions (e.g., new onset or 
worsening renal impairment) or who are receiving drugs needing monitoring 
with estimated creatinine clearance. 
• 
Coadministration of Tybost and tenofovir DF is not recommended in patients 
who have an estimated creatinine clearance below 70 mL/min because dose 
adjustment of tenofovir DF is required below 50 mL/min and such dose 
adjustments have not been established for coadministration with Tybost. 
• 
Coadministration of Tybost and tenofovir DF in combination with concomitant 
or recent use of a nephrotoxic agent is not recommended. 
The following ARVs are not recommended in combination with Tybost because 
dosing recommendations for such combinations have not been established, and 
co-administration may result in decreased plasma concentrations of the ARV 
agents, leading to loss of therapeutic effect and development of resistance: 
• 
More than one ARV that requires pharmacokinetic enhancement (i.e., two 
protease inhibitors or a protease inhibitor in combination with elvitegravir) 
• 
Atazanavir in combination with efavirenz in treatment-experienced patients 
• 
Atazanavir in combination with etravirine 
• 
Darunavir 600 mg twice daily 
• 
Darunavir in combination with efavirenz, nevirapine, or etravirine 
• 
Other HIV-1 protease inhibitors including fosamprenavir, saquinavir, or 
tipranavir 
• 
Tybost in combination with Stribild fixed-dose combination tablets (elvitegravir, 
cobicistat, emtricitabine, tenofovir DF) is not recommended because cobicistat 
is a component of Stribild. 
• 
Tybost in combination with lopinavir/ritonavir or regimens containing ritonavir 
is not recommended due to similar effects of Tybost and ritonavir on CYP3A. 
 


 
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Table 5.4.3-2: Precautionary Medications for BIC/FTC/TAF 
Medication/Drug Class 
Precautionary Medications 
Medications or oral supplements 
containing polyvalent cations 
(e.g., Mg, Al, Ca, Fe):  
Calcium or iron supplements  
Cation-containing antacids or 
laxatives  
Buffered medications 
• 
Antacids containing Al/Mg or Calcium: 
• 
BIKTARVY and supplements containing calcium 
or iron can be taken together with food. Routine 
administration of BIKTARVY under fasting 
conditions simultaneously with, or 2 hours after, 
supplements containing calcium or iron is not 
recommended. 
• 
BIKTARVY can be taken under fasting 
conditions 2 hours before antacids containing 
Al/Mg or calcium. 
• 
Routine administration of BIKTARVY 
simultaneously with, or 2 hours after, antacids 
containing Al/Mg or calcium is not 
recommended. 
• 
Supplements containing Calcium or Iron: 
Hypoglycemic agent 
• 
Metformin.  Refer to the prescribing information 
of metformin for assessing the benefit and risk 
of concomitant use of BIKTARVY and 
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6.0 
CLINICAL AND LABORATORY EVALUATIONS 
 
6.1 
Schedule of Evaluations (SOE) for Step 1 
 
Table 6.1-1:  Step 1 SOE 
Evaluation 
Screening Step 1  
Entry 
1 
2 
(section 
6.3.3) 
4 
8 
(section 
6.3.3) 
12 
24 
(section 
6.3.3) 
36 
48 
49 
(optional, 
section 
6.4.8) 
60 
72 
Virologic Failure  
Confirmation 
Premature 
Study/ 
Treatment 
Discontinuation 
-7 
days 
day 
0 
± 3 
days 
±7 
days 
±14 
 days 
-14 days to 
+3 days 
-3 days to 
+14 days 
± 42 
days 
Documentation of AHI 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Fiebig Staging 
 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
Demographics 
 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
Informed Consent 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Medical History 
X 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
Medication History 
X 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
Clinical Assessment 
 
X 
X 
 
X 
 
X 
X 
X 
X 
 
X 
X 
 
X 
Complete Physical 
Exam 
 
X 
 
 
 
 
 
 
 
 
 
 
 
 
X 
Targeted Physical Exam 
 
 
X 
 
X 
 
X 
X 
X 
X 
 
X 
X 
 
 
Height 
 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
Weight 
 
X 
X 
 
X 
 
X 
X 
X 
X 
 
X 
X 
 
X 
Signs, Symptoms, and 
Diagnoses 
 
X 
X 
 
X 
 
X 
X 
X 
X 
 
X 
X 
 
X 
Concomitant 
Medications 
 
 
X 
 
X 
 
X 
X 
X 
X 
 
X 
X 
 
X 
ART Modifications 
 
 
X 
 
X 
 
X 
X 
X 
X 
 
X 
X 
 
X 
ART Initiation 
 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
Hematology, 
Chemistries, Liver 
Function Tests 
 
X 
 
 
X 
 
X 
X 
 
X 
 
X 
X 
 
X 
Urinalysis 
 
X 
 
 
 
 
 
 
 
 
 
 
 
 
X 


 
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Evaluation 
Screening Step 1  
Entry 
1 
2 
(section 
6.3.3) 
4 
8 
(section 
6.3.3) 
12 
24 
(section 
6.3.3) 
36 
48 
49 
(optional, 
section 
6.4.8) 
60 
72 
Virologic Failure  
Confirmation 
Premature 
Study/ 
Treatment 
Discontinuation 
-7 
days 
day 
0 
± 3 
days 
±7 
days 
±14 
 days 
-14 days to 
+3 days 
-3 days to 
+14 days 
± 42 
days 
Pregnancy Testing 
(section 6.4.7) 
 
X 
If 
sus-
pected 
 
If 
sus-
pected 
 
Whenever pregnancy is suspected 
 
X 
CD4+/CD8+ T-cells 
 
X 
 
 
 
 
X 
X 
 
X 
 
X 
X 
X 
X 
PBMC and Plasma 
Storage 
 
X 
(section 
6.4.8) 
 
 
X 
 
X 
(section 
6.4.8) 
X 
(section 
6.4.8) 
 
X 
If needed 
X 
(section 
6.4.8) 
X 
(section 
6.4.8) 
 
 
Plasma HIV-1 RNA 
(section 6.4.9) 
 
X 
 
 
X 
 
X 
X 
X 
X 
 
X 
X 
X 
X 
HIV-1 Genotype  
(section 6.4.9) 
 
X 
 
 
 
 
 
 
 
 
 
 
 
X 
 
Total HIV-1 DNA by 
qPCR (section 6.4.9) 
 
X 
 
 
 
 
 
 
 
X 
If needed 
 
 
 
 
Telephone Evaluations 
(section 6.3.3) 
 
 
 
X 
 
X 
 
 
 
 
 
X 
 
 
Adherence Assessment 
and Counseling 
 
 
X 
 
X 
 
X 
X 
X 
X 
 
X 
X 
X 
 
Consent for Optional 
Procedures and Large 
Volume Blood Collection 
(after week 48; section 
6.4.11) 
 
X 
 
 
 
 
 
 
 
 
 
X 
 
 
Leukapheresis (optional 
as an alternative to large 
volume blood draw; 
(section 6.4.11) 
 
X 
 
 
 
 
 
 
 
 
 
 
 
 
Gut Biopsy  
(optional; section 6.4.11) 
 
 
 
 
 
 
 
 
 
 
 
X 
 
 
Lumbar Puncture 
(optional; section 6.4.11) 
 
 
 
 
 
 
 
 
 
 
 
X 
 
 
 
 


 
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6.2 
SOE for Step 2 
 
Table 6.2-1: Step 2 SOE 
Evaluation 
Step 2 
Registration 
Post-Step 2 Registration 
Evaluations (Weeks) 
Virologic Failure 
Confirmation 
Premature 
Study/Treatment 
Discontinuation 
Q24 
(24, 48, 72, 96, 120, and 144) 
Day 0 
± 60  
days 
Clinical Assessment 
X 
Q24 
 
X 
Complete Physical Exam 
X 
 
 
X 
Targeted Physical Exam 
 
Q24 
 
 
Weight 
X 
Q24 
 
X 
Confirmation of ART Continuation 
X 
Q24 
 
 
ART Modifications 
X 
Q24 
X 
X 
Hematology, Chemistries, Liver 
Function Tests 
X 
Q24 
(perform if needed, section 6.4.7) 
 
X 
Pregnancy Testing (section 6.4.7) 
X 
Whenever pregnancy is 
suspected 
 
X 
CD4+/CD8+ T-cells 
X 
Q48 
(record results from routine care, 
section 6.4.8) 
 
 
Plasma HIV-1 RNA (section 6.4.9) 
X 
Q24 
X 
X 
Adherence Assessment 
X 
Q24 
X 
 


 
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6.3 
Timing of Evaluations 
 
6.3.1 Screening Evaluations  
 
Screening evaluations must occur prior to the participant starting any study 
medications. 
 
Screening evaluations to determine eligibility must be completed within 7 days 
prior to study entry unless otherwise specified.  
 
NOTE: The screening evaluations can be combined with entry evaluations and 
can occur on the same day.  
 
In addition to data being collected on participants who enroll into the study, 
demographic, clinical, and laboratory data on screening failures will be captured 
in a Screening Failure Results form and entered into the ACTG database.  
 
6.3.2 Entry Evaluations 
 
Entry evaluations must occur after the screening evaluations, unless otherwise 
specified, and can occur on the same day.  
 
NOTE: All Step 1 post-entry evaluations occur in reference to the date on 
which the participant initiates ART treatment. All Step 2 post-entry 
evaluations occur in reference to the date of enrollment into Step 2.  
 
Participants must immediately initiate ART at the time of Step 1 study entry, 
ideally, within 24 hours but no later than 48 hours after registration/enrollment. If 
ART is not started within 48 hours after enrollment, the site staff should contact 
the protocol team immediately for approval to redraw blood samples for HIV-1 
RNA and Fiebig staging and to initiate ART on the same day as redraw.  
 
 
For participants who initiated ART more than 48 hours after enrollment and who 
did not have blood samples redrawn for HIV-1 RNA and Fiebig staging on the 
day of ART initiation, the site staff should contact the protocol team immediately 
for approval to redraw blood samples for HIV-1 RNA and Fiebig staging and to 
have the participants continue on ART. If allowed to remain on the study, their 
participation may end at the Step 1 week 24 visit if deemed by the study team 
that they are no longer eligible for the study based on the centralized testing 
results for Fiebig stage.  
 
Pregnancy testing should be done prior to ART initiation to inform selection of 
ART, but pregnancy is not an exclusion criterion for enrollment.  
 
HIV-1 RNA testing will also be performed at the time of study entry. Results of 
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initiation will not be delayed while awaiting confirmation of the entry HIV-1 RNA 
results.  
 
Results of baseline hematology, chemistry, and liver function testing will also 
generally be made available within 72 hours of study entry. The results of 
baseline laboratory evaluations and urinalysis will be reviewed with each study 
participant as part of the clinical assessment at week 1. ART may be dose-
adjusted, otherwise altered, or discontinued if the estimated glomerular filtration 
rate is reduced or other medical indications for therapeutic changes are detected.  
 
NOTE: ART must be started immediately even if the baseline safety laboratory 
results are not available within the 48-hour window.    
 
If an HIV-1 resistance genotype is performed as part of clinical care during 
screening or any time on the study, the results of that genotyping report will be 
collected. The site investigator may use this information to guide a change in 
ART, if clinically indicated, potentially including a change from the study-provided 
ARV regimen to a non-study-provided ARV regimen or a change from a non-
study-provided ARV regimen to the study-provided ARV regimen or a change 
between the two study-provided ARV regimens. Stored blood may be used 
for additional genotype testing for research purposes. This testing will not be 
done in real-time. 
 
6.3.3 Post-Entry Evaluations 
 
All post-entry evaluations occur in reference to the date of ART initiation.  
 
On-ART Step 1 Evaluations  
The on-treatment visits have the following window: 
• 
Weeks 1 and 2 (±3 days) for all participants 
• 
Weeks 4 and 8 (±7 days) for all participants 
• 
Weeks 12 and 24 (±14 days) for all participants  
• 
Week 36 (±14 days)  
• 
Week 48 (-14 days through +3 days)  
• 
Week 49 (optional, if needed to achieve blood volume collection goal at 
week 48; -3 days through +14 days)  
• 
week 60 and 72 (±42 days)  
 
Step 1 Telephone Evaluations   
Evaluations that are scheduled for weeks 2 and 8 on Step 1 will be completed 
by the site staff via telephone (in lieu of an in-person visit by the participant) and 
documented on the electronic case report form (eCRF). Site staff will call the 
participant to inquire about recent Grade ≥2 AEs and provide adherence 
counseling. If any Grade ≥2 AEs that require further investigation are reported, 
the participant may be asked to present for in-person evaluation. Follow-up 
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in the A5354 MOPS as guidance and for documentation of the telephone 
encounter(s). 
 
NOTE: The day following the optional gut biopsy via flexible sigmoidoscopy 
and/or lumbar puncture procedures to be performed between weeks 60 and 72, 
site staff will contact the participants via telephone to inquire how they are 
feeling, which will be documented on the eCRF (refer to section 6.4.11 for 
additional information). If any symptoms are present on the day of the initial 
telephone call, follow-up phone calls to the participants are recommended. Site 
staff must ensure that the follow-up phone calls are completed as part of the 
follow-up of optional procedure evaluations. 
 
Step 2 Evaluations 
The Step 2 Registration evaluation may be combined with the Step 1 Week 
72 visit. If the Step 2 Registration visit is not combined, then all Step 2 
evaluations must be performed within 2 weeks after the final Step 1 visit.  
Those participants re-enrolling into the study after going off study at week 
72 under protocol Version 1.0 will complete all evaluations listed in the 
Step 2 Registration column. 
 
All visits following Step 2 registration will have a ± 60-day visit window.  
 
Study Completion Evaluations  
The week 24 visit on Step 1 will be the final study visit for participants who 
initiated ART during Fiebig VI (based on confirmed Fiebig stage results), and 
these participants will be replaced. For Step 2, the final visit will occur at 
week 144 for all the study groups, except in cases of premature study 
discontinuation as described in section 6.3.5. Upon study completion, ART 
will no longer be provided through the study (i.e., post-trial access to ART is not 
within the scope of A5354). The study team will ensure that participants are 
referred to appropriate health facilities to continue their ART. After the study 
ends, ART regimens may be modified according to local practices and decision 
by the participants and their physicians. 
 
6.3.4 Confirmation of Virologic Failure (VF) Evaluation on Step 1 and Step 2 
 
VF is defined as having two consecutive HIV-1 RNA >200 copies/mL 24 weeks 
or more after study entry, or at any time after achieving HIV-1 RNA <50 
copies/mL. A confirmatory plasma HIV-1 RNA measurement and other 
evaluations per sections 6.1 and 6.2 should be done as soon as possible, 
ideally within 7 to 14 days of the initial sample with a HIV-1 RNA >200 copies/mL. 
If the visit for HIV-1 RNA confirmation coincides with a regularly scheduled visit, 
the evaluations should be combined. Refer to section 6.3.5 for instructions on 
the discontinuation evaluations for participants who have confirmed VF. 
Participants who interrupt ART for ≥7 consecutive days prior to meeting 
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NOTE: If genotyping is performed as part of routine care, then the results will be 
documented in the eCRF. Stored blood may be used for additional genotype 
testing for research purposes.  
 
6.3.5 Discontinuation Evaluations 
 
Evaluations for Registered Participants Who Do Not Start ART 
For participants who do not initiate ART per section 6.3.2, all eCRFs must be 
keyed for the period up to and including the entry visit. These participants are 
not required to complete any study discontinuation visit. These 
participants will be replaced. 
 
Evaluations for Registered Participants Found NOT to Have HIV-1 Infection 
Participants who initiated ART and are subsequently determined not to have HIV-
1 infection will stop all ART, undergo a study discontinuation visit (refer to 
sections 6.1 and 6.2 for discontinuation evaluations), and discontinue study 
follow-up (refer to section 6.4.9 for the HIV-1 RNA detectable threshold 
requirement). These participants will be replaced. 
 
Premature Study Discontinuation Evaluations  
Participants who are confirmed to have VF or prematurely discontinue from the 
study for other reasons will have the study discontinuation evaluations 
performed (per sections 6.1 and 6.2) within 12 weeks of being notified of the 
need for study discontinuation. This may include recruitment for 
participation in future studies that enroll participants who initiated ART 
during AHI. In such cases, A5354 study discontinuation evaluations should 
be performed at or before enrollment into the new study.  
 
6.3.6 ART Interruption  
 
Participants who interrupt ART for ≥7 consecutive days will be considered for 
withdrawal from the study. If the ART interruption occurs prior to study 
week 24 on Step 1 and the participant has not previously demonstrated an 
HIV-1 RNA <50 copies/mL (prior to the interruption lasting ≥7 consecutive 
days), then the participant will be withdrawn from the study and undergo 
the premature study discontinuation evaluation (section 6.3.5), after which 
study drug will no longer be provided. This visit should occur by week 24 
on Step 1, or within 12 weeks of being notified of the need for study 
discontinuation, whichever is later. This timeline should allow the study 
staff and participant to identify an alternative source of medication.  
 
If the participant has previously been documented to have HIV-1 RNA <50 
copies/mL or the ART interruption occurs at study week 24 or later in Step 
1 or Step 2, then the participant will be evaluated for VF (section 6.3.4). If 
the confirmatory HIV-1 RNA results indicate VF, then the participant will be 
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evaluation. If the confirmatory HIV-1 RNA results do not indicate VF, then the 
participant will remain in the study for continued follow-up and will complete all 
scheduled study evaluations per sections 6.1 and 6.2, except no PBMC and 
plasma collection will be performed after the collection at week 48 on Step 1 
and no optional procedures at week 60 or 72 on Step 1.  
 
6.4 
Instructions for Evaluations 
 
Each study site and laboratory involved in this study will comply with the DAIDS policy on 
Requirements for Laboratories Performing Testing for DAIDS-Supported and/or 
Sponsored Clinical Trials, which is available at: 
https://www.niaid.nih.gov/sites/default/files/laboratorypolicy1.pdf. 
 
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/daids-sourcedocpolicy.pdf. 
 
All stated evaluations are to be recorded on the eCRF unless otherwise specified. 
Refer to section 7.0 for information on the Division of AIDS Table for Grading the 
Severity of Adult and Pediatric Adverse Events (DAIDS AE Grading Table), and AE 
reporting of adverse events requirements.  
 
6.4.1 Documentation of AHI 
 
Section 4.1.1 specifies assay requirements for documentation of the diagnosis of 
AHI by local laboratories per standard of care. HIV-1 documentation will be 
recorded on the eCRF. 
 
6.4.2 Fiebig Staging  
 
Characterization of Fiebig stage using samples collected at the time of study 
entry will be performed by a designated central laboratory, and results will be 
available within 12 weeks after enrollment, which will help determine total follow-
up period in the study (section 6.3.2 for details). Fiebig staging will be assigned 
according to the following table: 
 
Table 6.4.2-1. Fiebig Staging Assignment by Study Group 
Study 
Group* 
Fiebig 
Stage 
Markers 
HIV-1 
RNA 
and/or 
IgM 
and/or 
WB or Geenius 
HIV-1/HIV-2 
1 
I/II 
+ 
And 
- 
 
- 
2 
III/IV 
+ 
And 
+ 
and 
-/indeterminate 
3 
V 
+ 
And 
+/- 
and 
+ without p31 band 
 
VI 
+ 
And 
+/- 
and 
+ with p31 band 
Adapted from Fiebig AIDS 2003 


 
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Refer to section 6.4.9 for additional information and the A5354 Laboratory 
Processing Chart (LPC) for instructions related to the collection, processing, and 
shipping of these samples. 
 
6.4.3 Demographics 
 
Some socio-demographic information (e.g., substance use, education) will be 
documented on the eCRF. 
 
6.4.4 Medical History 
 
The medical history must include all diagnoses identified by the ACTG criteria for 
clinical events and other diagnoses. In addition to reporting all diagnoses within 
the past 30 days, the following diagnoses should be reported regardless of when 
the diagnosis was made:  
• 
Acute HIV-1 
• 
Bone fractures (verbal history accepted) 
• 
Coronary heart disease 
• 
Cancer (exclusive of basal/squamous cell skin cancer) 
• 
Diabetes 
• 
Tuberculosis 
• 
Chronic hepatitis C 
• 
Chronic hepatitis B 
• 
Renal disease 
 
Any allergies to any medications and their formulations must also be 
documented.  
 
6.4.5 Medication History 
 
A medication history must be present, including start and stop dates. The table 
below lists the medications that must be included in the history.  
 
Table 6.4.5-1: Medication History  
Medication Category 
Complete History or Timeframe 
ART 
Complete history  
Immune-based therapy 
Within 90 days prior to study entry 
HIV-1-related vaccines 
Within 2 years prior to study entry 
Drugs for treatment of opportunistic infections Within 90 days prior to study entry 
Drugs for treatment of medical conditions 
Grade ≥2 as reported in the medical history 
Within 90 days prior to study entry 
Sex-hormone medications or sex-
hormone analogues or antagonists* 
Last 12 months except as noted 
below 
*Includes: Hormone-releasing IUDs (e.g., Mirena inserted in the last 5 years); oral, 
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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. 
 
6.4.6 Clinical Assessments 
 
The results of baseline laboratory evaluations and urinalysis will be reviewed with 
each study participant as part of the clinical assessment at week 1. 
 
Complete Physical Exam 
At entry and the premature study/treatment discontinuation visits, a complete 
physical examination is to include at a minimum an examination of the skin, 
head, mouth, and neck; auscultation of the chest; cardiac exam; abdominal 
exam; and examination of the lower extremities for edema. The complete 
physical exam will also include signs and symptoms, diagnoses, and vital signs 
(temperature, pulse, and blood pressure per local standard of care). 
 
Targeted Physical Exam 
At the post-entry visits, a targeted physical examination is to include vital signs 
(temperature, pulse, and blood pressure) and is to be driven by any previously 
identified or new signs or symptoms, including diagnoses that the participant has 
experienced since the last visit.  
 
Post entry, refer to section 8.9 for collection requirements for pregnancy. 
 
Height 
Height will be recorded per the SOE. 
 
Weight 
Weight will be recorded per the SOE. 
 
Signs and Symptoms 
At Step 1 entry, signs and symptoms of all grades that occurred within 30 days 
prior to entry must be recorded as medical history. Please refer to section 7.2 for 
AE reporting requirements for post-entry signs and symptoms.  
 
At Step 2 entry, record SAEs and chronic medical conditions per section 
6.4.4 for re-enrolled participants who completed the study under protocol 
Version 1.0.  
 
Diagnoses 
At Step 1 entry, all diagnoses that are described in section 6.4.4 must be 
recorded as medical history. Please refer to section 7.2 for AE reporting 
requirements for post-entry diagnoses. 
 


 
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At Step 2 entry, record SAEs and chronic medical conditions per section 
6.4.4 for re-enrolled participants who completed the study under protocol 
Version 1.0. 
 
Concomitant Medications 
For post-entry, record new or discontinued concomitant medications for 
prophylaxis and treatment of opportunistic infections and other medical 
conditions since the last study visit, including actual or estimated start dates and 
stop dates.  
 
ART Modifications  
All modifications to ARV medications including initial doses, participant-initiated 
and/or protocol-mandated interruptions (that are ≥7 days), modifications, 
permanent discontinuations, and last doses on study will be recorded.  
 
In Step 2, all modifications to ARV medications will be recorded.  
 
ART Initiation   
ART must be initiated at the time of study entry, ideally, within 24 hours but no 
later than 48 hours after registration/study entry. If ART is not initiated within 48 
hours after enrollment, and the participant remains eligible based on at least one 
inclusion criteria in section 4.1.1, the site staff should contact the protocol team 
immediately for approval to redraw blood samples for HIV-1 RNA and Fiebig 
staging and to initiate ART on the same day as redraw.  
 
For participants who initiated ART more than 48 hours after enrollment and who 
did not have blood samples redrawn for HIV-1 RNA and Fiebig staging on the 
day of ART initiation, the site staff should contact the protocol team immediately 
for approval to redraw blood samples for HIV-1 RNA and Fiebig staging and to 
have the participants continue on ART. If allowed to remain on the study, their 
participation may end at week 24 if deemed by the study team that they are no 
longer eligible for the study.  
 
6.4.7 Laboratory Evaluations 
 
At Step 1 entry and Step 2 registration, record all protocol-required laboratory 
values (performed by local laboratories) with exception of the urinalysis, 
regardless of grade. For post-entry assessments, record all laboratory values for 
creatinine, CrCl, AST (SGOT), and ALT (SGPT) regardless of grade.  
 
Please refer to section 7.2 for AE reporting requirements for abnormal laboratory 
findings. 
 
NOTE: Creatinine clearance should be graded using the categorical mL/min 
values from the DAIDS AE Grading Table, which begins with values below 
90 mL/min. The percent change criteria will not apply to A5354. In Step 2, 
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Hematology, Chemistries, and Liver Function Tests 
• 
Hemoglobin or hematocrit, white blood cells, and platelets. 
• 
Serum creatinine will be tested and used to calculate CrCl using the Cockroft-
Gault equation. Refer to the calculator located on the FSTRF website. 
 
AST and ALT 
Other laboratory tests for the optional procedures between weeks 60 and 72: 
• 
Prothrombin time/partial prothrombin time for the optional procedures 
• 
Complete blood count for the optional gut biopsy  
 
NOTE: Refer to the A5354 MOPS for additional information on these laboratory 
tests for the optional procedures. 
 
At Step 1 entry, the safety laboratory results for CrCl, AST, and ALT will 
generally be available to the site within 72 hours after study entry and ART 
initiation. If necessary, the ARV regimen will be immediately adjusted upon 
recognition of relevant laboratory abnormalities, and site staff must notify the 
CMC of the adjustment in ART. The results of baseline laboratory evaluations will 
be reviewed with each study participant as part of the clinical assessment at 
week 1.  
 
In Step 2, record the results of the safety laboratory tests, if available as 
part of routine care. Perform only if not done and available as part of 
routine care. 
 
Urinalysis 
Blood, glucose, leukocyte esterase, pH, and protein. Reflex to microscopic 
urinalysis if dipstick result is abnormal. Urinalysis will be performed per 
section 6.1. At Step 1 entry, the safety urinalysis result will generally be 
available to the site within 72 hours after study entry and ART initiation. The 
results of baseline urinalysis will be reviewed with each study participant as part 
of the clinical assessment at week 1.  
 
Pregnancy Test 
For women of reproductive potential: urine β-HCG (urine test must have a 
sensitivity of 15-25 mIU/mL) or serum β-HCG test may be performed. Pregnant 
women who meet the eligibility criteria are allowed to enroll in the study. Record 
pregnancy and pregnancy outcome per section 8.0.  
 
At Steps 1 and 2 entry, the pregnancy test is to be performed, and the results 
must be available at the site prior to the first dose of ART in order to inform the 
appropriate selection of ART.  
 
Pregnancy testing post-entry will be performed if pregnancy is suspected. 
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study for continued follow-up. Pregnant participants will be switched from the 
study-provided ARV regimen to an alternative ART. Refer to section 8.9 for 
information on the management of participants who are pregnant at study entry 
or become pregnant while on study.   
 
6.4.8 Immunologic Studies 
 
CD4+/CD8+ T-cells 
Obtain absolute CD4+/CD8+ T-cell count and percentages during the study from 
a laboratory that possesses a CLIA certification or equivalent (US sites) or 
IQA certification (non-US sites). 
 
In Step 2, record the results from the laboratory tests (if available) that are 
performed as part of routine care. Do not perform if results are not 
available from routine care. 
 
HIV-1-Specific T-Cell Responses 
PBMC and plasma will be collected, frozen, and stored for studies of HIV-1-
specific T-cell responses. In addition, the PBMC samples will be shipped in batch 
for HLA typing and CCR5 delta-32 genotyping at the end of the study. Please 
refer to the A5354 LPC for instructions related to the collection, processing, and 
shipping of these samples. 
 
Participants will have blood collected for PBMC and plasma storage at the 
visits indicated in the SOE. At the Step 1 entry visit, PBMC and plasma will 
be obtained from large volume blood collection (or the optional 
leukapheresis, as an alternative to the large volume blood draw).   
 
At week 49 (if needed), blood collected may be pooled with, or tested in lieu 
of, blood collected at Step 1 week 48 to obtain a sufficient quantity for any 
assays. 
At weeks 60 and 72 on Step 1, PBMC and plasma storage will be obtained. 
 
For participants who started ART during Fiebig VI, PBMC and plasma storage 
will not be performed at weeks 12 and 24 after Step 1 entry. 
 
For participants who interrupt ART for ≥7 consecutive days before Step 1 week 
48 of the study, their last PBMC and plasma storage will be at week 48 on Step 
1. If such interruption occurs after week 48, no PBMC and plasma storage will be 
performed at future visits. 
 
6.4.9 Virologic Studies 
 
Plasma HIV-1 RNA 
At Steps 1 and 2 entry, a real-time HIV-1 RNA test will be performed. For HIV-1 
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at screening but meet the AHI inclusion criteria (section 4.1.1, part b or c), the 
plasma HIV-1 RNA result at Step 1 entry must be ≥500 copies/mL to be 
considered truly positive for HIV-1 infection. If the entry HIV-1 RNA result does 
not meet this detectable threshold value, the participant will be discontinued from 
the study. 
 
For post-entry HIV-1 RNA (real-time) evaluations, the laboratory must be certified 
by the DAIDS Virology Quality Assurance (VQA) Program.  
 
Fiebig Stage 
At entry, additional plasma samples will be collected and shipped to the 
designated central laboratory for testing to determine the Fiebig stage of 
participants. Please refer to the A5354 LPC for instructions related to the 
collection, processing, and shipping of these samples. 
 
HIV-1 Genotype  
Samples will be collected at the time points indicated in the SOE and shipped to 
the designated central laboratory. Sites should refer to the A5354 LPC for 
instructions related to the collection, processing, and shipping of these samples. 
 
Genotyping at entry and at the time of VF may be performed on stored samples 
for research purposes; therefore, results will not be available in a timely manner 
for clinical management. Entry plasma samples will be tested for reverse 
transcriptase (RT) and protease (PR) resistance in those participants who did not 
have baseline genotype performed as part of standard of care. If genotyping is 
performed per standard of care, sites should document the results in the eCRF. 
 
For participants who experienced VF on study, a plasma sample will be collected 
for later genotyping. Samples for genotyping can either be from the initial visit 
with the HIV-1 RNA rise or at the time of confirmation of VF. Samples with HIV-1 
RNA above 1000 copies/mL are preferred for genotyping. Resistance testing will 
include RT, PR, and integrase resistance testing. A plasma sample collected at 
entry from these same participants will be forwarded for integrase resistance 
testing. These genotypes are being performed for research purposes, and results 
will not be available in a timely manner for clinical management. Therefore, sites 
should follow local standard practice regarding real-time genotyping at AHI 
diagnosis and at the time of VF. 
 
NOTE: If an HIV-1 resistance genotype is performed as part of clinical care 
during screening or any time on the study (section 6.3.2), the site investigator 
may use this information to guide a change in ART, if clinically indicated, 
including a change from the study-provided ARV regimen to a non-study-provided 
ARV regimen or a change from a non-study-provided ARV regimen to the study-
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Total HIV-1 DNA 
CAHD will be assayed by qPCR in 2 million CD4+T-cells from the Step 1 entry 
time point in participants who have undetectable CAHD at week 48 to ensure 
that each participant’s viral DNA can be amplified by the qPCR assay. This will 
exclude false negative results for HIV-1 DNA detection at the primary endpoint 
(week 48) resulting from PCR primer mismatch or other inhibitors of PCR in the 
participant’s sample.  
 
 Total HIV-1 DNA will be obtained either from the stored PBMC and plasma 
or large volume blood collection (or optional leukapheresis). 
 
Primary Endpoint Determination 
Please refer to the A5354 LPC for instructions related to the collection, 
processing, and shipping of these samples. 
6.4.10 Adherence Assessment and Counseling 
  
Adherence to ART will be evaluated by self-report at all visits after study entry. 
Counseling to promote adherence to ART will be provided by site staff at all visits 
after study entry.  
 
The adherence eCRF is posted on the DMC Portal in the Forms 
Management Utility. 
 
6.4.11 Optional Procedures and Large Volume Blood Collection 
 
Based on the primary endpoint determination results (after week 48), you 
may be asked to provide consent for the optional procedures to be 
performed between weeks 60 and 72. 
 
Participants will be encouraged to undergo at least one or both of the 
following procedures on Step 1:  
• 
Gut Biopsy  
• 
Lumbar Puncture  
 
The following conditions will render a participant ineligible from 
participating in the optional procedures:  
• 
Pregnancy 
• 
ART interruption ≥7 consecutive days at any point on Step 1 
• 
Virologic failure 
 
Telephone follow-up will be performed by site staff the day following the gut 
biopsy and/or lumbar puncture to inquire about any AEs from the procedure. If 
any symptoms potentially related to the recent research procedure are present 
on the day of the initial telephone call, follow-up phone calls or in-person visits 
(depending upon the type of symptoms or signs) are recommended. If any AEs 


 
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that require further investigation are reported, the participant should be asked to 
present for in-person evaluation by a site clinician. Events meeting the reporting 
requirement in section 7.1 must be recorded in the eCRF. 
 
Large Volume Blood Collection OR Optional Leukapheresis 
A large volume blood collection for plasma and PBMC storage will take 
place at the Step 1 entry visit. Sites may choose to offer leukapheresis as 
an alternative to the large volume blood draw at Step 1 entry.  
 
NOTE: Sites will not be reimbursed for the leukapheresis performed at Step 1 
entry. Only the routine PBMC and plasma collection or large volume blood draw 
will be covered at this visit.  
 
Refer to the A5354 LPC for instructions related to the processing, shipping, 
and storage of these samples. 
 
Gut Biopsy 
Gut biopsy specimens via flexible sigmoidoscopy will be collected at any time on 
Step 1 from week 60 to week 72 in participants who consent to this procedure. 
Please refer to the A5354 LPC for instructions related to the processing, 
shipping, and storage of these samples. 
 
NOTE: Participants must abstain from receptive anal intercourse for 3 days 
before and 7 days after the biopsy.  
 
Lumbar Puncture 
CSF will be collected via lumbar puncture and will be performed at any time on 
Step 1 from week 60 to week 72 in participants who consent to this procedure. 
Please refer to the A5354 LPC for instructions related to the processing, 
shipping, and storage of these samples. 
 
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 
protocol imposed intervention). This includes any occurrence that is new in onset or 
aggravated in severity or frequency from the baseline condition.  
 
All AEs must be reported in the clinical database if the reporting criteria have been met 
for any diagnoses, signs and symptoms, and abnormal laboratory findings as described 
below. AEs that meet the definition of a serious adverse event (SAE) or expedited 
adverse event (EAE), as defined in section 7.3, must also be recorded.  
 


 
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7.2 
Adverse Event Collection Requirements  
 
Post-entry, all AEs must be reported on the eCRFs if the reporting criteria have 
been met. 
• 
All Grade ≥3 signs and symptoms 
• 
All Grade ≥2 laboratory findings 
• 
All targeted diagnoses (refer to the list on the A5354 PSWP) 
• 
All AEs that led to a change in study treatment/intervention regardless of 
grade 
• 
All AEs meeting SAE definition or EAE reporting requirement 
 
NOTE: Uterine pregnancy does not require reporting as an AE (unless other SAE 
criteria are met) but must still be recorded on the eCRFs. 
 
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 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 events listed above. 
 
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 AEs are 
outlined in Version 2.0 of the DAIDS EAE Manual, which is available on the RSC 
website at https://rsc.niaid.nih.gov/clinical-research-sites/manual-expedited-
reporting-adverse-events-daids. 
 
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 


 
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the DAIDS EAE Form. 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. 
Sites where DAERS has not been implemented will submit expedited AEs by 
documenting the information on the current DAIDS EAE Form. This form is 
available on the RSC website: https://rsc.niaid.nih.gov/clinical-research-
sites/paper-eae-reporting. For questions about EAE reporting, please contact 
the RSC (DAIDSRSCSafetyOffice@tech-res.com). 
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 is required are 
EVG/COBI/FTC/TAF and BIC/FTC/TAF. 
 
7.3.3 Grading Severity of Events 
 
The DAIDS AE Grading Table, corrected Version 2.1, July 2017, must be used 
and is available on the DAIDS RSC website at 
https://rsc.niaid.nih.gov/clinical-research-sites/daids-adverse-event-
grading-tables. 
 
7.3.4 Expedited AE Reporting Period 
 
• 
The expedited AE reporting period for this study is as per the Version 2.0 of 
the EAE Manual. 
• 
After the protocol-defined EAE reporting period, unless otherwise noted, only 
suspected, unexpected serious adverse reactions (SUSARs), as defined in 
Version 2.0 of the DAIDS EAE Manual, will be reported to DAIDS if the site 
staff become aware of the events on a passive basis (from publicly available 
information). 
 
7.4 
Study Monitoring 
 
Refer to section 10.5. 
 
8.0 
CLINICAL MANAGEMENT ISSUES 
 
Criteria for participant management, dose interruptions, modifications, and 
discontinuation or changes will be mandated for toxicities attributable to the study-


 
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provided drug, EVG/COBI/FTC/TAF or BIC/FTC/TAF. Participants who are receiving 
any non-study-provided ARV regimen should have toxicities managed for that drug 
according to the standard of care. NOTE: Site investigators are encouraged to consult 
the A5354 CMC for management of ART toxicities regardless of the ARV regimens 
being used. 
 
Every effort should be made to retain participants on study as long as participant safety 
is maintained. If treatment-limiting drug toxicity occurs, site investigators working closely 
with primary care providers are encouraged to choose an alternative site-provided ART 
regimen based on their clinical assessment, standard of care at their site, and participant 
preference. Such regimen changes do not necessitate discontinuation of study 
participation. The A5354 CMC must be notified by e-mail regarding study drug toxicities 
that result in a change in regimen or discontinuation (actg.cmcA5354@fstrf.org). 
 
If there is a treatment-limiting toxicity resulting from STR EVG/COBI/FTC/TAF or 
BIC/FTC/TAF, then the individual formulations of any component drug may be given 
along with a drug substitution, if necessary. However, the individual formulations will not 
be provided through the study. 
 
The DAIDS AE Grading Table, corrected Version 2.1, July 2017, will be used for the 
grading of drug toxicities and is available on the DAIDS RSC website at 
https://rsc.niaid.nih.gov/clinical-research-sites/daids-adverse-event-grading-
tables.  
 
8.1 
Toxicity  
 
The general guidelines presented in the subsequent sections below apply to toxicities 
that are not specifically addressed further in the DAIDS AE table. Because the goal of 
this study is to maximally reduce HIV-1 reservoir size with early treatment, continued 
viral suppression on ART is critical. For any ongoing medical condition present prior 
to study entry and unrelated to ART, the study ART may be initiated provided that 
the site investigator deems it is in the best interest of the study participants.  
 
With the occurrence of AEs that are probably, possibly, or definitely related to the 
participant’s ART, every attempt should be made to switch to safe alternative regimens. 
However, if there are no safe alternative regimens or the treating physician deems that it 
is in the participant’s best interest to discontinue all ART, the ART must be promptly 
stopped. Participants who interrupt ART for ≥7 consecutive days must have HIV-1 RNA 
repeated as soon as possible and evaluated for possible VF (refer to section 6.3.4). 
 
8.1.1 Grade 1 or 2 
 
Participants who develop a Grade 1 or 2 AE or toxicity should continue ART 
unless deemed unsafe, and further management will be at the discretion of the 
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8.1.2 Grade 3 
 
If the site investigator has compelling evidence that the AE has NOT been 
caused by the participant’s ART, dosing may continue and further management 
will be at the discretion of the site investigator. If the toxicity is thought to be 
related to ART, the regimen should be held or switched to site-provided 
alternative ART at the discretion of the site investigator, with the goal being to 
maximize tolerability and minimize time off ART. Medications other than 
EVG/COBI/FTC/TAF or BIC/FTC/TAF will not be provided by the study protocol. 
Regardless of whether therapy is continued, stopped, or switched, the participant 
should be re-evaluated closely, preferably weekly, until the AE returns to Grade 
≤2. Consultation with the A5354 CMC is encouraged if there are questions about 
appropriate management.  
 
NOTE: The abnormal laboratory result(s) must be back to an acceptable level, as 
judged by the site investigator, prior to restarting therapy for any toxicity that led 
to a drug substitution or discontinuation.  
 
If AE returns to Grade ≤2 after regimen discontinuation or switch and original 
ART is restarted with recurrence of the same Grade 3 AE within 4 weeks, the 
implicated drug(s) should be permanently discontinued. If the same Grade 3 AE 
recurs after 4 weeks but is not thought to be related to the ART, the management 
scheme outlined above may be repeated. Participants experiencing Grade 3 AEs 
requiring permanent discontinuation or modification of ART should be followed 
closely until resolution of the AE.  
Participants with Grade 3 asymptomatic abnormalities in hemoglobin, hematocrit, 
white blood cells, platelets, creatinine phosphokinase, or liver enzymes may 
continue study drugs.  
 
8.1.3 Grade 4 
 
Participants who develop a Grade 4 symptomatic AE or toxicity that is attributed 
to the study-provided ART must have their ART discontinued or switched to an 
alternative regimen if felt appropriate by the site investigator. After modification of 
regimen, participants should be followed closely until resolution of the AE (to a 
Grade ≤2 or a level deemed acceptable by the site investigator), after which if 
treatment was discontinued it may be restarted with substitution of another drug. 
Those who require ART interruption for ≥7 consecutive days must have HIV-1 
RNA repeated as soon as possible and evaluated for possible VF. Details on 
ART interruption are described in section 6.3.6.   
 
Participants with Grade 4 asymptomatic laboratory abnormalities not specifically 
addressed below may continue ART if the site investigator has compelling 
evidence that the toxicity is NOT related to the regimen. 
 


 
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Participants with Grade 4 asymptomatic abnormalities in hemoglobin, hematocrit, 
white blood cells, platelets, or creatinine phosphokinase may continue study-
provided drug.  
 
8.2 
Rash 
 
NOTE: In the event that Grade 2, 3, or 4 rash fails to resolve, increases in severity, is 
associated with systemic (e.g., fever) or allergic (e.g., urticaria) symptoms or 
Grade 3 or 4 LFT elevations, or is associated with exfoliative dermatitis or 
mucous membrane involvement or erythema multiforme, or suspected Stevens-
Johnson syndrome or necrosis requiring surgery, all ART and other potentially 
implicated medications must be discontinued until symptom resolution. The 
A5354 CMC must be consulted.  
 
8.2.1 Grade 1 or 2 
 
If the rash is considered to be likely due to concomitant illness or drug, standard 
management, including discontinuation of the likely causative agent, should be 
undertaken. If no other causative factor is found after clinical evaluation, the 
participant should be treated symptomatically until the rash resolves. 
Antihistamines, topical corticosteroids or antipruritic agents may be prescribed. 
The participant should be advised to contact the site staff immediately if there is 
any worsening of the rash. It is extremely important to closely monitor the 
participant to ensure that symptoms do not worsen. Additional guidance to avoid 
drug interactions is described in section 5.4. 
 
8.2.2  Grade 3 
 
If the rash is thought to be related to an ART agent, participants should 
discontinue their drug. An alternative ART regimen may be substituted with the 
goal of maximizing tolerability and minimizing time off ART. The A5354 CMC 
must be consulted regarding management. 
 
8.2.3 Grade 4 
 
Participants should discontinue all ART and other potentially implicated 
medications. The A5354 CMC must be consulted regarding management. 
 
8.3 
Diarrhea 
 
Symptomatic treatment of diarrhea, regardless of grade, with oral antidiarrheal drugs, or 
modification of ART with site-provided medications is permitted at the discretion of the 
site investigator. If Grade ≥3 diarrhea thought to be related to current ART persists 
despite symptomatic management, then the regimen should be held or modified with 
site-provided medications at the discretion of the site investigator until it resolves to 
Grade ≤2. The site staff is encouraged to consult with the A5354 CMC. 
 


 
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8.4 
Nausea/Vomiting 
 
Nausea/vomiting, regardless of grade, may be managed with symptomatic agents such 
as oral antiemetics or antiemetic suppositories, or modification of ART with site-provided 
medications at the discretion of the site investigator. For Grade ≥3 nausea/vomiting 
thought secondary to ART that fails to improve on antiemetics, the regimen may be held 
or modified with site-provided medications until resolution to Grade ≤2. If Grade ≥3 
nausea/vomiting recurs with reintroduction of initial ART, the regimen should be 
permanently discontinued with the option to substitute with site-provided alternative 
regimens at the discretion of the site investigator. The A5354 CMC must be consulted in 
these situations.  
 
If nausea/vomiting thought to be related to ART, then an alternative regimen may be 
substituted at any time at the provider’s discretion with the goal of maximizing tolerability 
and minimizing time off ART. The site staff is encouraged to consult with the A5354 
CMC.  
 
8.5 
Liver Enzyme Elevations 
 
8.5.1 Grade ≤3  
 
The participant’s ART may be continued for asymptomatic, isolated Grade ≤3 
AST (SGOT) or ALT (SGPT) elevations at the discretion of the site investigator. 
Careful assessments should be done to rule out the use of alcohol, non-study 
drug-related toxicity, or viral hepatitis as the cause of the liver enzyme elevation.  
 
For symptomatic Grade 3 elevations of AST (SGOT) or ALT (SGPT), the ART 
should be held or changed to alternative site-provided medication until toxicity 
returns to Grade ≤2. However, ART may be continued for Grade 3 elevations 
that are unrelated to ART at the discretion of the site investigator. If 
symptomatic Grade 3 elevation recurs on rechallenge with ART, the regimen 
should be permanently discontinued and the A5354 CMC must be consulted.  
 
An alternative ART regimen may also be substituted at any time at the provider’s 
discretion with the goal of maximizing tolerability and minimizing time off ART.  
 
8.5.2 Grade 4 
 
The ART should be held or modified to alternative site-provided regimen at 
the discretion of the site investigator for confirmed asymptomatic AST 
(SGOT) or ALT (SGPT) Grade 4 elevations that are related to ART. Laboratory 
follow-up should be performed until the toxicity returns to Grade ≤2. If Grade 
≥3 elevation in AST (SGOT) or ALT (SGPT) recurs on rechallenge with 
previously used regimen, these drugs should be permanently discontinued 
and the A5354 CMC must be consulted.   
 


 
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Any symptomatic Grade 4 AST (SGOT) or ALT (SGPT) elevation that is 
believed to be related to ART should lead to permanent discontinuation of the 
regimen with immediate consultation with the A5354 CMC.  
 
For asymptomatic and symptomatic Grade 4 AST (SGOT) and/or ALT 
(SGPT) elevations that are not related to ART, the ART may be continued at 
the discretion of the site investigator provided that it is felt to be in the best 
interest of the participant.  
 
Careful assessments should be done to rule out the use of alcohol, non-study 
drug-related toxicity, or viral hepatitis as the cause of the Grade 4 elevation. 
 
8.6 
Headache 
 
Analgesics, anti-migraine drugs, muscle relaxants, and other symptomatic 
treatment should be used at the discretion of the site investigator. If the 
headache is considered to be most likely due to concomitant illness or drug, 
standard management, including discontinuation of the likely causative agent, 
should be undertaken. If the headache is thought to be related to their ART, the 
participant should be managed at the discretion of the site investigator. The 
participant should be advised to contact the site investigator immediately if there 
is any worsening of the headache. If the regimen is discontinued, the A5354 
CMC must be consulted. An alternative ART regimen may also be substituted at 
any time at the site investigator’s discretion with the goal of maximizing 
tolerability and minimizing time off ART. 
 
8.7 
Hypophosphatemia 
 
8.7.1 Grade 3 
 
For Grade 3 hypophosphatemia, participants should be given oral supplements 
or foods high in phosphates, with close follow-up at the discretion of the 
investigator. For persistent Grade 3 hypophosphatemia despite supplementation, 
consideration should be given to holding any TDF or TAF-containing regimens as 
outlined for Grade 4 hypophosphatemia. An alternative ART regimen may also 
be substituted at any time at the provider’s discretion with the goal of maximizing 
tolerability and minimizing time off ART. 
 
8.7.2 Grade 4 
 
For Grade 4 hypophosphatemia, hold any TDF or TAF-containing regimens and 
switch to an alternative site-provided drug. Participants should be given oral 
phosphate supplements or foods high in phosphates. Retest phosphate levels 
weekly until they return to Grade ≤1.  
 
Continuation of supplemental phosphate is at the discretion of the site 
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TDF or TAF-containing regimen and phosphate supplementation, neither TDF 
nor TAF-containing regimens should be reinitiated.   
 
8.8  
Renal Insufficiency 
 
CrCl should be calculated from the serum creatinine using the Cockroft-Gault equation. 
Providers should consider testing for HLA-B5701 in any participant with renal 
insufficiency in anticipation of a potential switch of ART to an abacavir-containing 
regimen, if not already taking in order to maximize participant safety and minimize time 
off ART. 
 
For participants prescribed study-provided EVG/COBI/FTC/TAF, any CrCl <30 mL/min 
or >0.4 mg/dL increase from baseline creatinine value should be confirmed by repeat 
testing within 1 week. If the calculated CrCl remains <30 mL/min, the regimen must be 
permanently discontinued and alternative regimen initiated. Participants with confirmed 
serum creatinine increases >0.4 mg/dL above baseline should undergo an evaluation for  
potential causes of decreased renal function and should have serum creatinine 
monitored more frequently, at the discretion of the site investigator, until serum 
creatinine either stabilizes or decreases to ≤0.4 mg/dL above baseline.  
 
Management of increasing creatinine or declining CrCl on any site-provided ART should 
be managed per the standard of care at the discretion of the site investigator with the 
goal of maximizing tolerability and minimizing time off ART.  
 
The A5354 CMC must be consulted for any discontinuation or modification of ART due 
to renal insufficiency.  
 
8.9 
Pregnancy and Breastfeeding  
 
Pregnant and breastfeeding women are allowed in the study, assuming they meet other 
eligibility criteria, and an appropriate alternative ARV regimen is available according to 
local standard practice. Participants who are pregnant or breastfeeding should not be 
prescribed EVG/COBI/FTC/TAF or BIC/FTC/TAF.  
 
Women who are diagnosed with pregnancy following enrollment and are on study-
provided EVG/COBI/FTC/TAF or BIC/FTC/TAF or site-provided regimen not 
recommended in pregnancy should be switched to a regimen that is suitable for use 
during pregnancy and/or breastfeeding according to the local standard practice. 
 
Incident pregnancies that occur while on study should be reported prospectively to The 
Antiretroviral Pregnancy Registry. More information is available at www.apregistry.com. 
Phone: 800-258-4263; Fax: 800-800-1052. (For studies conducted at sites outside the 
US: Report to The Antiretroviral Pregnancy Registry; Fax: 44-1628-789-666 or 910-246-
0637; Phone: 910-679-1598.)  
 


 
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Pregnant women will continue on study on an alternative non-study-provided ARV 
regimen and will follow the schedule of evaluations outlined in section 6.1, with 
exception of the optional procedures and large volume blood collection. 
 
For women who deliver and elect not to breastfeed or for those who complete 
breastfeeding, ARV regimens can be switched to study-provided EVG/COBI/FTC/TAF or 
BIC/FTC/TAF.  
 
If a pregnant woman has completed the study prior to delivery or if she elects to 
prematurely discontinue from the study before the end of the pregnancy, then site staff 
should request permission to contact her regarding pregnancy outcomes following 
delivery. This permission should be explicitly documented, and the women should be 
contacted within 2 weeks of her due date to obtain this information.  
 
Any intrapartum complications, pregnancy, and pregnancy outcome will be recorded on 
the eCRFs.  
 
8.10 
Lumbar Puncture 
 
The most common complication is positional headache (12-24 hours post-procedure), 
believed to be due to post-procedure leakage from the puncture site.  
 
The primary therapy for this is to lie down. The headache subsides within minutes of 
lying down and if the participant stays inactive over a day or two the leakage stops. In 
rare cases where it is prolonged, or the participant must move about, a blood patch can 
be injected over the site of the puncture, effectively blocking the leakage. If a pencil point 
needle is used, the risk of lumbar puncture headache is small (<10%) and a blood patch 
is rarely needed. Participant should stay hydrated and limit strenuous activities, 
especially lifting of heavy weights for 24 hours after lumbar puncture or until post-
procedure headache resolves. Contact with the participant on the day following the 
procedure is recommended. Heat and over-the-counter analgesics may be used if low 
back pain at the site of the puncture develops. Participant should be seen if any 
indication of significant increased disability is experienced. 
 
8.11 
Leukapheresis 
 
On rare occasions, an allergic reaction to the citrate used during leukapheresis will 
require that the procedure be stopped early. Symptoms should be treated according to 
the site’s standard practice.  
 
8.12 
Gut Biopsy 
 
On extremely rare occasions, the gut biopsy via flexible sigmoidoscopy may cause pain, 
infection, bleeding, or perforation of the intestinal tract. If such a complication occurs, the 
participant will have appropriate clinical management in conjunction with the participant’s 
health care provider.   
 


 
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9.0 
CRITERIA FOR DISCONTINUATION 
 
9.1 
Premature Study Drug Discontinuation 
 
• 
Drug-related toxicity (section 8.1) 
• 
Requirement for prohibited concomitant medications (section 5.4) 
• 
Pregnancy and/or breastfeeding 
• 
Request by participant to discontinue treatment 
• 
Clinical reasons believed life-threatening by the physician, even if not addressed in 
the toxicity section of the protocol 
 
9.2 
Premature Study Discontinuation 
 
• 
Never started ART 
• 
Started ART after 48 hours after enrollment and determined by the protocol team to 
be ineligible for continued participation 
• 
Does not have HIV-1 infection 
• 
Participant confirmed to be Fiebig VI will discontinue after week 24 in Step 1. 
• 
Failure by the participant to attend three consecutive study visits 
• 
Participant has confirmed VF as defined in section 6.3.4 
• 
In Step 1, interrupted ART ≥7 consecutive days and has not previously 
demonstrated an HIV-1 RNA <50 copies/mL (prior to the interruption lasting ≥7 
consecutive days) 
• 
Request by the participant to withdraw, including withdrawal to enable 
participation in another study. 
• 
Request of the primary care provider if s/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, 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 
 
This is a prospective, open-label study to measure the effects of early ART on the 
establishment of HIV-1 reservoir and HIV-1-specific immunity. Participants with AHI will 
have an enrollment visit and initiate ART at the time of enrollment. Each participant will 
be followed on study for up to 216 weeks (72 weeks on Step 1 and 144 weeks on 
Step 2) unless they are Fiebig VI at ART initiation in which case their last visit will be no 
later than week 24 on Step 1. The primary endpoint is CAHD in 5 million blood-derived 
CD4+ T-cells assayed by qPCR at week 48 on Step 1. Only participants who have not 
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consecutive days of ART and have HIV-1 RNA <50 copies/mL at week 48 on Step 1 will 
be included in the primary efficacy analysis. If adequate sample and analyzable data 
are not available from the week 48 visit, week 49 will be used instead.  
 
Characterization of Fiebig stage using samples at the time of ART initiation will be 
performed with results known within 12 weeks based on standardized, centralized 
testing; this will define the analysis groups. Each study group had a target enrollment 
of 50 participants under protocol Version 1.0. Study Groups 2 and 3 have reached 
their target enrollment and therefore the original inclusion criteria from protocol 
Version 1.0 corresponding to these groups are no longer applicable for eligibility 
into the study. Because Fiebig stage for the analysis comparison will not be known until 
after therapy is initiated, over-enrollment based on available data at the time of entry 
may be implemented. 
 
10.2 
Outcome Measures  
 
10.2.1 Primary Outcome Measures 
 
10.2.1.1 CAHD per 5 million CD4+ T-cells at week 48 on Step 1 
 
10.2.2 Secondary Outcome Measures  
 
10.2.2.1 HIV-1-specific CD4+ and CD8+ T-cell responses to nef/tat/rev/vpr/vpu, 
gag, pol and env by flow cytometry prior to ART initiation and while 
HIV-1 RNA is suppressed on ART 
 
10.2.2.2 Cell-associated HIV-1 RNA per 5 million CD4+ T-cells prior to ART 
initiation and while HIV-1 RNA is suppressed on ART 
 
10.2.2.3 Cell-associated HIV-1 RNA/DNA ratio in participants with detectable 
CAHD prior to ART initiation and while HIV-1 RNA is suppressed on 
ART 
 
10.2.3 Other Outcome Measures  
 
10.2.3.1 Frequency of non-transmitted epitope escape mutants prior to ART 
initiation and week 48 on Step 1 
 
10.2.3.2 CAHD, HIV-1-specific immune responses and single copy HIV-1 RNA 
in blood; CAHD in gut; and CAHD and single copy HIV-1 RNA in CSF 
at any time on Step 1 from week 60 to week 72 in participants who 
consent and undergo the optional procedures and have available data  
 
10.2.3.3 Innate immune responses such as NK cells, ADCC, and ADCP prior to 
ART initiation and while HIV-1 RNA is suppressed on ART 
 


 
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10.2.3.4 Different HIV-1 molecular forms (unintegrated HIV-1 DNA, integrated 
HIV-1 DNA, total HIV-1 DNA) in participants with detectable CAHD 
prior to ART initiation and while HIV-1 RNA is suppressed on ART 
 
10.2.3.5 Genetic factors such as HLA typing and CCR5 delta-32 genotyping, 
including relationships with virologic and immunologic outcomes prior 
to ART initiation and while HIV-1 RNA is suppressed on ART 
 
10.2.3.6 Integration sites prior to ART initiation and while HIV-1 RNA is 
suppressed on ART 
 
10.3 
Randomization and Stratification 
 
There is no randomization or stratification. 
 
10.4 
Sample Size and Accrual  
 
The primary study objective is to compare the primary outcome measure at week 48 on 
Step 1 after ART dichotomized as: 0 versus >0 copies of CAHD in 5 million blood-
derived CD4+ T-cells. The groups are expected to differ in likelihood that a participant 
has no detectable total HIV-1 DNA, with percentages estimated to be: 
Fiebig I/II: 
75% 
Fiebig III/IV: 
25% 
Fiebig V: 
<5% 
 
Forty-two (42) virologically suppressed participants at week 48 on Step 1 per group will 
provide high power to detect differences between all three groups based on this primary 
endpoint: >95% power for Fiebig I/II versus III/IV, >95% power Fiebig I/II versus V and 
80% power for Fiebig III/IV versus V (assuming 3.5% for Fiebig V participants), based on 
Fisher’s exact test with type I error rate of 0.05 for each pairwise comparison. Table 
10.4-1 below shows power for the comparison between Fiebig I/II versus III/IV with 
different underlying probability of undetectable cell-associated HIV-1 DNA at week 48 
with 42 participants per group. The study will have moderate power (76%) to detect a 
difference between the two groups even with higher estimated probability in Fiebig III/IV 
group (35%) and lower estimated probability in Fiebig I/II group (65%).  
 
Table 10.4-1: Power Comparisons 
 
Fiebig III/IV 
Fiebig I/II 
25% 
30% 
35% 
75% 
>95% 
>95% 
95% 
70% 
>95% 
95% 
88% 
65% 
95% 
88% 
76% 
 
It is further assumed that 90% of participants who initiate study treatment will remain 
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15% lost to follow-up rate and insufficient samples at primary outcome week, the 
total sample size is 196 (a target enrollment of 50 per group).  
 
NOTE: Groups 2 and 3 closed to enrollment under protocol Version 1.0. 
 
The sample size increase to 196 participants is intended to aid in meeting the 
accrual target for Group 1 and increase the number of early-treated participants 
engaged in the cohort that are potentially eligible for future studies. This is an 
estimation of the additional number of participants that will need to be enrolled in 
order to fully accrue Group 1 (since group assignment is unknown at the time of 
enrollment), based on the current rate of participants who were estimated to be in 
Group 1, and determined to be in Group 1 at study entry after centralized testing.   
 
Based on the available Fiebig staging data as of May 15, 2019, after the 
completion of centralized testing, 31% of participants estimated to be in Group 1 
were determined to be in Group 1, while 50% were determined to be in Group 2.  
Group 1 has enrolled 37 participants. Group 2 had enrolled 63 participants, and 
Group 3 had enrolled 54 participants. Assessing the current group counts and 
rates, we anticipate that, with 196 participants enrolled (an additional 36 
enrollments after replacing Fiebig VI and HIV negative participants), approximately 
50 participants will be determined to be in Group 1. 
 
Secondary objectives are largely exploratory without formal sample size calculation.  
However, based on data from the RV254 study, HIV-1-specific CD4+ T-cell responses to 
gag after ART are expected to be 15% in Fiebig I/II versus 30% in Fiebig III/IV versus 
80% in Fiebig V which will provide 30% power for Fiebig I/II versus III/IV, >90% power 
for Fiebig V versus the other two groups.  
 
It is anticipated that the study will take 36 months to accrue with one third of the 
participants accrued during the first 6 months after at least three international sites have 
enrolled at least one participant.  
 
10.5 
Data and Safety Monitoring 
 
Accrual, baseline characteristics (including baseline laboratory values), conduct of the 
study (including premature study discontinuations, data availability and sample 
acquisition), any ART interruptions, VFs, and all reported toxicities and AEs will be 
monitored by the team during the study. The team will also closely monitor the Fiebig 
stages of the study population as defined by the standardized testing of samples 
obtained at ART initiation. In addition, the study will be reviewed by a Study Monitoring 
Committee (SMC) according to ACTG standard operating procedures. The SMC will 
review accrual, baseline characteristics (including baseline laboratory values), Fiebig 
stage at ART initiation, AE summaries, CD4+ T-cell counts and HIV-1 RNA 
levels/suppression over time, study and ART discontinuations (and reasons), and 
completeness of follow-up and sample availability. The SMC will convene, at a minimum, 
6 months after the first participant is enrolled or after 25 participants are enrolled, 
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Furthermore, the CMC or the team may, at any time it thinks appropriate, ask for the 
SMC to independently review all available safety data.  
 
Since characterization of Fiebig stage using samples at the time of ART initiation will be 
performed with results known within 12 weeks based on standardized, centralized 
testing, an estimated Fiebig group at enrollment based on inclusion criteria from section 
4.1.1, as shown in the table below will provide additional real-time monitoring for 
accruals into each study group. Each Fiebig stage from I through IV has a median 
duration of approximately 5 days, the Fiebig stage at 7 days prior to enrollment may be 
expected to advance by one or possibly two stages by the time of enrollment. Both 
Fiebig stage determinations (centralized tested or estimated by inclusion criteria) will be 
used to guide accrual once enrollment is completed in at least one Fiebig group. For 
instance, Groups 2 and 3 have reached their enrollment target under protocol 
Version 1.0, thus enrollment is closed for those two groups.  
 
Table 10.5-1. Expected Fiebig Group Based on Inclusion Criteria (section 4.1.1) 
Inclusion 
Criteria # 
Inclusion Criteria Details 
Expected 
Fiebig Group 
a 
A detectable HIV-1 RNA obtained within 28 days prior 
to study entry AND a non-reactive HIV-1 antibody 
within 7 days prior to entry 
Group 1 (Fiebig 
I-II) 
b 
ARCHITECT or GSCOMBO S/CO ≥10 within 7 days 
prior to entry AND a non-reactive HIV-1 antibody within 
7 days prior to entry 
Group 1 (Fiebig 
I-II) 
c 
ARCHITECT or GSCOMBO S/CO ≥1 within 7 days 
prior to entry AND a non-reactive HIV-1 antibody within 
7 days prior to entry AND a known prior S/CO <0.5 
within 90 days prior to entry 
Group 1 (Fiebig 
I-II) 
d 
ARCHITECT or GSCOMBO S/CO >0.5 but <10 within 7 
days prior to entry AND a non-reactive HIV-1 antibody 
within 7 days prior to entry AND detectable HIV-1 RNA 
within 7 days prior to entry 
Group 1 (Fiebig 
I-II) 
 
10.6 
Analyses 
 
Analysis of the primary efficacy will be restricted to participants who maintain HIV-1 
RNA <50 copies/mL at week 48 on Step 1 with no ART interruption of ≥7 consecutive 
days and have available CAHD results from week 48 or week 49. Specifically, plasma 
HIV-1 RNA by commercial assay must be <50 copies/mL at week 48 with no prior VF 
(section 6.3.4). This study is designed to evaluate the effect of suppressive ART initiated 
in different stages of AHI on the establishment and persistence of HIV-1 reservoirs; this 
is the rationale for analyzing HIV-1 DNA only among virally suppressed participants and 
not in those with incompletely suppressed viremia (>50 copies/ml). Primary outcome 
measures will be summarized as a binary outcome, 0 copies versus >0 copies of CAHD 
per 5 million CD4+ T-cells assessed separately and jointly by gag- and integrase-
assays. Each participant’s primary endpoint sample will be tested twice by gag- 


 
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and integrase-assays. For the primary outcome measure, in order for a participant 
to be considered as having 0 copies of CAHD, the participant must be found to 
have an undetectable CAHD result from both assays. Proportion of 0 copies of 
CAHD will be compared pairwise between groups using Fisher’s exact test. 95% 
confidence interval for the proportion estimated will be calculated using the exact 
binomial distribution. The analysis groups will be Fiebig I/II, Fiebig III/IV, and Fiebig V, as 
defined by the standardized testing of samples at ART initiation. Supplemental 
analyses will use Wilcoxon rank sum test to compare the primary outcome measure on 
the continuous scale between analysis groups, separately for the results from the 
gag- and integrase assays. We will also examine the primary outcome measures that 
include participants with extended periods of ART interruption (≥7 consecutive days) 
while maintained HIV-1 RNA <50 copies/mL at week 48. For clades with sufficient data, 
supplemental sensitivity analyses will compare Fiebig stages stratified by HIV subtype.  
 
Study and study treatment discontinuations (and reasons) will be summarized. In 
addition, use of non-study-provided ART will be summarized including reasons (if any) 
for participants to change from study-provided ARV regimen to non-study-provided ARV 
regimen.  
 
Analysis of secondary outcome measures will use the same approach as for the primary 
outcome measure if the outcome is binary. Wilcoxon rank-sum tests will be used to 
compare the continuous secondary outcome measures between groups. Rank-based 
Spearman correlations will describe association between outcome measures. 
 
11.0 
PHARMACOLOGY PLAN 
 
Not applicable. 
 
12.0 
DATA COLLECTION AND MONITORING  
 
12.1 
Records to Be Kept 
 
eCRFs 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 registration. 
 
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 the data in a timely fashion. 
 
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. 
 


 
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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 ACTG, local IRB/EC, the site monitors, the NIAID, 
the OHRP, the industry supporter or designee, other local, US, and 
international regulatory entities for confirmation of the study data. 
 
13.0 
PARTICIPANTS 
 
13.1 
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, NIAID, OHRP, 
other local, US, and international regulatory entities as part of their duties, or the 
industry supporter or designee.  
 
13.3 
Study Discontinuation 
 
The study may be discontinued at any time by the ACTG, IRB/EC, NIAID, OHRP, or 
other country-specific government agencies as part of their duties to ensure that 
research participants are protected, or the industry supporter or designee.  
 


 
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14.0 
PUBLICATION OF RESEARCH FINDINGS 
 
Publication of the results of this trial will be governed by ACTG policies. Any 
presentation, abstract, or manuscript will be made available for review by the industry 
supporter prior to submission.  
 
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 Centers for 
Disease Control and Prevention 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. Soudeyns H, Campi G, Rizzardi G, et al. Initiation of antiretroviral therapy during primary 
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18. Altfeld M, Rosenberg E, Shankarappa R, et al. Cellular immune responses and viral 
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20. Lécuroux C, Girault I, Urrutia A, et al. Identification of a particular HIV-specific CD8+ T-
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23. Pantaleo G, Graziosi C, Demarest J, et al. HIV infection is active and progressive in 
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24. Chun T, Nickle D, Justement J, et al. Persistence of HIV in gut-associated lymphoid 
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25. Yukl S, Wong J. Blood and guts and HIV: preferential HIV persistence in GI mucosa. J 
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26. Yukl S, Sinclair E, Somsouk M, et al. A comparison of methods for measuring rectal HIV 
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27. Ananworanich J, Schuetz A, Deleage C, et al. Sigmoid lamina propria CD4 T cell 
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30. Ramos E, Harb S, Dragavon J, Swenson P, Stekler J, Coombs R. Performance of an 
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31. Ramos E, Harb S, Dragavon J, Coombs R. Clinical performance of the Multispot HIV-
1/HIV-2 rapid test to correctly differentiate HIV-2 from HIV-1 infection in screening 
algorithms using third and fourth generation assays and to identify cross reactivity with 
the HIV-1 Western Blot. J Clin Virol 2013;58:e104-7. 
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recency of HIV-1 infection. In: Conference on Retroviruses and Opportunistic Infections 
(CROI 2015); Feb 23-26, 2015; Seattle, WA, USA.  
33. Cillo A, Sobolewski M, Bosch R, et al. Quantification of HIV-1 latency reversal in resting 
CD4+ T-cells from patients on suppressive antiretroviral therapy. Proc Natl Acad Sci U S 
A 2014;111:7078-83. 
34. DeJesus E, Rockstroh JK, Henry K, et al. Co-formulated elvitegravir, cobicistat, 
emtricitabine, and tenofovir disoproxil fumarate versus ritonavir-boosted atazanavir plus 
co-formulated emtricitabine and tenofovir disoproxil fumarate for initial treatment of HIV-
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35. Sax PE, DeJesus E, Mills A, et al. Co-formulated elvitegravir, cobicistat, emtricitabine, 
and tenofovir versus co-formulated efavirenz, emtricitabine, and tenofovir for initial 
treatment of HIV-1 infection: A randomised, double-blind, phase 3 trial, analysis of 
results after 48 weeks. Lancet 2012; 379:2439-48. 
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37. Sax PE, Wohl D, Yin MT, et al. Tenofovir alafenamide versus tenofovir disoproxil 
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38. White K, Cihlar T, Miller MD. Potent activity of bictegravir (BIC; GS-9883), a novel 
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39. Tsiang M, Kan E, Tsai L, et al. Antiviral activity of GS-9883, a potent next generation 
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40. Jones G, Goldsmith J, Mulato A, et al. Bictegravir (GS-9883), a novel HIV-1 integrase 
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41. Sax PE, DeJesus E, Crofoot G, et al. Bictegravir versus dolutegravir, each with 
emtricitabine and tenofovir alafenamide, for initial treatment of HIV-1 infection: a 
randomised, double-blind, phase 2 trial. Lancet HIV 2017;4:e154-e160. doi:  
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42 Lundgren JD, Babiker AG, Gordin F, et al. Initiation of antiretroviral therapy in early 
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43. Danel C, Moh R, Gabillard D, et al. A trial of early antiretrovirals and isoniazid preventive 
therapy in Africa. N Engl J Med 2015;373:808-22. Epub 2015 Jul 20. 
44. Baeten JM, Donnell D, Ndase P, et al. Antiretroviral prophylaxis for HIV prevention in 
heterosexual men and women. N Engl J Med 2012;367:399-410. 
45. Baeten JM, Donnell D, Mugo NR, et al. Single-agent tenofovir versus combination 
emtricitabine plus tenofovir for pre-exposure prophylaxis for HIV-1 acquisition: an update 
of data from a randomised, double-blind, phase 3 trial. Lancet Infect Dis 2014;1:1055-64. 
46. Thigpen MC, Kebaabetswe PM, Paxton LA, et al. Antiretroviral preexposure prophylaxis 
for heterosexual HIV transmission in Botswana. N Engl J Med 2012;367:423-34.  
47. Van Damme L, Corneli A, Ahmed K, et al. Preexposure prophylaxis for HIV infection 
among African women. N Engl J Med 2012;367:411-22. 
48. McAllister J, Read P, McNulty A, Tong WW, Ingersoll A, Carr A. Raltegravir-
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50. Sheffield JS, Wendel GD Jr, McIntire DD, Norgard MV. The effect of progesterone levels 
and pregnancy on HIV-1 coreceptor expression. Reprod Sci 2009;16:20-31.  
51. Gray RH, Li X, Kigozi G, et al. Increased risk of incident HIV during pregnancy in Rakai, 
Uganda: A prospective study. Lancet 2005;366:1182-8. 
52. Moodley D, Esterhuizen TM, Pather T, Chetty V, Ngaleka L. High HIV incidence during 
pregnancy: Compelling reason for repeat HIV testing. AIDS 2009;23:1255-9. 
53. Moodley D, Esterhuizen T, Reddy L, et al. Incident HIV infection in pregnant and 
lactating women and its effect on mother-to-child transmission in South Africa. J Infect 
Dis 2011;203:1231-4. 
54. Dinh TH, Delaney KP, Goga A, et al. Impact of maternal HIV seroconversion during 
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55. Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the use of 
antiretroviral agents in HIV-1-infected adults and adolescents. Department of Health and 
Human Services. Available at: 
http://aidsinfo.nih.gov/contentfiles/lvguidelines/AdultandAdolescentGL.pdf. Accessed 28 
January 2016. 
56. Panel on Treatment of HIV-Infected Pregnant Women and Prevention of Perinatal 
Transmission. Recommendations for Use of Antiretroviral Drugs in Pregnant HIV-1-
Infected Women for Maternal Health and Interventions to Reduce Perinatal HIV 
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APPENDIX I:  SAMPLE INFORMED CONSENT 
 
DIVISION OF AIDS 
AIDS CLINICAL TRIALS GROUP (ACTG) 
 
A5354 
Effect of Antiretroviral Treatment Initiated During Acute HIV-1 Infection on Measures of HIV-1 
Persistence and on HIV-1-Specific Immune Responses 
FINAL Version 2.0, December 31, 2019  
 
 
SHORT TITLE FOR THE STUDY: A5354/EARLIER (Early ART to Limit Infection and 
Establishment of Reservoir) 
 
 
SUMMARY 
 
PURPOSE: 
The purpose of this study is to have persons who are newly or 
recently infected with HIV-1 (the virus that causes AIDS) to start 
taking anti-HIV medicine (antiretroviral (ARV) drugs) right away. The 
study will look at how starting antiretroviral treatment (ART), as 
soon as the HIV-1 infection is found, affects the amount of HIV-1 
virus and HIV-1 infection-fighting cells (CD4+ and CD8+ T-cells) in 
your blood. The study will also look at the amount of HIV-1 DNA (the 
genetic material for HIV-1) is seen in CD4+ T-cells after you have 
been on ART for 48 weeks.  
 
 
The study will provide elvitegravir/cobicistat/emtricitabine/ tenofovir 
alafenamide (EVG/COBI/FTC/TAF) and 
bictegravir/emtricitabine/tenofovir alafenamide (BIC/FTC/TAF). The 
study doctor will have you take one of these study-provided 
medicine or a non-study-provided ARV medication. You must be on 
ART while participating in this study. 
 
NUMBER OF 
 
PARTICIPANTS: 
Up to 196 people will take part in this study. 
 
LENGTH OF 
STUDY: 
The study will last about 5 years for most people. There are two 
parts to the study. Part 1 will take about 1 year and 6 months, and 
Part 2 will take about 3 years.  
 
You may need to stay at the clinic for almost half a day at some 
visits. You will have up to nine study visits in the first year of Part 1; 
two of these visits will be done by telephone. In the next year of Part 
1 of the study, you will have up to two clinic visits. In Part 2 of the 


 
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study, you will need to come for study visits two times each year for 
the next three years. 
 
REQUIRED 
 
ACTIVITIES: 
Blood and urine collections 
At most visits, some blood will be collected from a vein in your arm. 
At entry and if you leave or stop the study early, you will be asked to 
provide a urine sample.  
  
Special procedure 
At entry of Step 1, a large amount of blood will be collected from a 
vein in your arm or instead of this large volume blood draw, an 
optional procedure called leukapheresis may be performed. The 
leukapheresis procedure uses a machine that allows for collection 
of white blood cells (infection-fighting cells in your blood). This 
procedure may take 1½ to 3 hours. 
 
 
RISKS: 
EVG/COBI/FTC/TAF and BIC/FTC/TAF have been tested in humans 
and are approved by the US Food and Drug Administration (FDA). 
There are, however, some risks when taking these drugs. Below are 
some common drug reactions seen with these drugs when given to 
people.  
• 
Headache 
• 
Diarrhea or loose, watery stools 
• 
Nausea or vomiting 
• 
Abdominal pain 
• 
Tiredness or weakness 
• 
Rash 
 
If you are taking EVG/COBI/FTC/TAF, you may also experience 
worsening or new damage or failure to your kidney, pancreas, or 
liver.  
 
If you are living with hepatitis B virus (HBV) and taking BIC/FTC/TAF, 
there is a possibility of an unexpected worsening of hepatitis B if 
you stop taking BIC/FTC/TAF.  
 
 
BENEFITS: 
No direct benefits should be expected from participating in this 
study.  
 
 
OTHER CHOICES: 
Instead of being in this study, you have the option of receiving care 
from your primary provider or other health care providers. 


 
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INTRODUCTION 
 
You are being asked to take part in this research study for two main reasons: 
1. You are living with acute human immunodeficiency virus type 1 (HIV-1, the virus that 
causes AIDS). Acute infection means that you recently got HIV.  
2. You are willing and able to start taking antiretroviral therapy (ART, anti-HIV drugs) right 
away. 
 
This study is sponsored by the National Institutes of Health (NIH). The doctor in charge of this 
study at this site is: (site: insert name of Principal Investigator). Before you decide if you want to 
be part of this study, we want you to know more 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? 
 
The study is being done to:  
• 
start ART early in those recently or acutely infected with HIV-1 
• 
see how starting ART as soon as the infection is found affects the amount of HIV-1 in your 
blood and how well your body fights the HIV-1 infection 
• 
look at the amount of HIV-1 DNA (genetic material for HIV-1) seen in CD4+ T-cells 
(infection-fighting cells in your blood) after 48 weeks of ART  
• 
see how early treatment for HIV affects the numbers of HIV-1 infection fighting cells (CD4+ 
and CD8+ T-cells) in your blood 
 
 
HOW MANY PEOPLE WILL TAKE PART IN THIS STUDY? 
 
Up to 196 people (men and women age 18 years and older) who have acute HIV-1 infection will 
take part in this study. 
 
 
HOW LONG WILL I BE IN THIS STUDY? 
 
You will be in this study between about 1 year and 6 months and about 4 years and 6 
months depending on when you join.  
 
 
WHAT DO I HAVE TO DO IF I AM IN THIS STUDY? 
 
If you decide to join this study, you will first need to be screened for the study to make sure that 
you qualify. You will start taking ART at study entry. At study entry, a sample of your blood will 
be tested to confirm your HIV-1 infection. At the time of starting ART, an additional sample of 


 
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your blood will be tested to see how far along you are with your HIV-1 infection; this is called 
Fiebig staging. There are three study groups determined by Fiebig staging. Based on your 
medical records of HIV testing and the results from the day that you start the HIV medications, 
the study team will determine which study group you will be included in.  
 
The study will provide two tablets – each tablet contains 3 to 4 different drugs. Three of these 
drugs treat HIV, and one is a drug that increases the levels of one of the anti-HIV drugs. The 
names of these drugs are elvitegravir/cobicistat/emtricitabine/ tenofovir alafenamide 
(EVG/COBI/FTC/TAF) and bictegravir/emtricitabine/tenofovir alafenamide (BIC/FTC/TAF). 
These drugs have been approved by the US Food and Drug Administration.  
 
If you are not able to take the study-provided drug, then you will be allowed to take the best 
ART available to you, as prescribed by your primary care doctor. These non-study-provided 
ART must be obtained locally.  
 
Both you and your doctor will know which drugs you are taking. The study staff will work 
with you to make sure you are taking your medication correctly. 
 
There are two parts to the study, which are described below. 
 
If you are eligible and enter the study, you will need to come for study visits up to nine times 
in the first year of Part 1 of the study; two of these visits will be done by telephone. If during 
these telephone visits, the study staff determines that you should be seen in person, you will be 
asked to go to the clinic. In the next year of Part 1 of the study, you will have up to two clinic 
visits that will include the study staff contacting you by telephone the day after completing the 
optional procedures (gut biopsy and/or lumbar puncture). You will be notified by the study staff 
of when to expect to receive these telephone calls before you are actually called.  
 
If after completing the visit 72 weeks (about 1 year and 6 months) after entering the study 
in Part 1 (under either Version 1.0 or Version 2.0), you remained virologically suppressed 
(having HIV-1 viral load levels <50 copies/mL), never stopped ART for 7 days or more, 
and did not have detectable levels of HIV-1 viral load (higher than what the study would 
allow), you will enter Part 2 of the study. You will be asked to come for study visits two 
times each year for approximately the next 3 years. Part 2 of the study has limited 
evaluations and no invasive procedures.  
 
NOTE: Groups 2 and 3 closed to enrollment since the accrual goal was met under 
protocol Version 1.0.   
  
Most clinic visits will last about 1 hour. The study staff will tell you how long each visit will last.  
 
NOTES:  
• 
If your laboratory tests from entry show that you do not qualify for the study, the study staff 
will tell you to stop all ART. You will be asked to complete the discontinuation evaluations, 
and your follow-up will end.   
• 
After you enter the study, if your blood test shows that you have had HIV longer than 
expected at the time of entry, then your follow-up and HIV study treatment will end at week 


 
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24. Your doctor will tell you the results of the tests by week 12 so you will have time to 
pursue HIV treatment outside of the study.  
• 
If you stop taking your ART for 7 or more days in a row, the last peripheral blood 
mononuclear cells (PBMC, cells separated from the blood taken from you) and plasma (the 
liquid part of blood taken from you) collection will be done at week 48.  
 
You may need to come to the clinic for extra visits if you develop side effects or if you need to 
switch to non-study-provided ART or if the level of HIV in your blood increases after it has been 
undetectable. More information about the study procedures is given at the end of this consent 
(Attachment A). During the study, you will receive results, when they are available, from any 
routine tests that are done during the study. 
 
At most visits, we will collect blood samples for routine safety labs and study-required tests. 
Some of your blood will be stored (with protectors of identity) and used for immunologic, 
resistance, and genetic testing that is required for this study. 
 
You will get the site’s usual adherence support (procedures to help you remember to take your 
ART).  
 
If you do not enroll into the study 
After signing this consent form, if you decide not to take part in this study or if you do not meet 
the eligibility requirements, the study team will still use some of your information. There is some 
information that we collect on everyone who is screened for an ACTG study. As part of 
this screening visit, some demographic (for example, age, gender, race), clinical (for example, 
disease condition, diagnosis), and laboratory (for example, HIV-related blood test results) 
information will be collected from you. We also collect information on whether you use (or 
have used) IV drugs. 
 
We will collect this information even if you do not enroll in this study. This information is 
collected so that ACTG researchers may determine whether there are patterns and/or 
common reasons why people do not join a study. 
 
Extra Samples and Blood Collections 
Part of the entry visit includes taking a larger amount of blood (large volume blood draw) than 
what is collected on a typical blood draw. At some sites, blood will be collected during a medical 
procedure called leukapheresis, which may be performed in place of large volume blood 
collection at entry. For this procedure, you will need to be in a semi-reclining or reclining position 
for most of this time. By collecting blood using this procedure, researchers are able to get many 
more white blood cells than is usually possible. For additional information, see Attachment B of 
Appendix I. 
 
After week 48 on Part 1 of the study, you may be asked whether you agree to have additional 
procedures done and samples collected. You will be provided more information about these 
additional procedures during that visit. These additional procedures are optional and include gut 
biopsy by flexible sigmoidoscopy and lumbar puncture (see Appendix II for additional 
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the future. No matter what you decide, it will not affect your participation in the study. About 25 
people participating in this study will take part in these two optional procedures.  
 
At non-US sites, biological specimens may be shipped and/or stored outside the country from 
which they were collected (e.g., sites that do not have a central testing laboratory in-country). 
 
NOTE: If you are pregnant or become pregnant on study, these optional procedures will not be 
done. If you stop taking ART for 7 days or more in a row or if you have a viral load 
that is confirmed to be more than or equal to 50 copies/mL, you will not be able to 
participate in the gut biopsy and lumbar puncture optional procedures. 
 
 
CAN I CHOOSE THE TYPES OF RESEARCH THAT MY SAMPLES AND INFORMATION 
ARE USED FOR? 
 
Some of your blood will be stored and used for study-required immunologic and 
virologic testing.  
 
Identifiers will be removed from your samples and from any private information that has 
been collected about you. This means that no one looking at the labels or at other 
information will be able to know that the samples or information came from you.  
 
The tests described above are required by this study. If you do not agree to the storage 
or testing that has been described above, you should not join this study.  
  
Some blood that is collected from you during the study might be left over after all 
required study testing is done. This blood will be stored and, if you give your consent 
below, may be used for ACTG-approved research. This means that researchers who are 
not part of the protocol team may use your samples without asking you again for your 
consent. As noted above, none of your samples will have any private information about 
you on their labels.  
 
You may decide whether this “extra” blood may be stored and, if so, whether additional 
testing may be performed on it. You may withdraw your consent for research on your 
extra samples at any time and the specimens will be discarded. 
 
You will not be paid for your samples. Also, a researcher may make a new scientific 
discovery or product based on the use of your samples. If this happens, there is no plan 
to share any money with you. The researcher is not likely to ever know who you are. 
 
At this time, we do not know whether any of the research will include testing of your 
genes or your DNA (your own genetic information). We do not know whether a type of 
testing called whole genome sequencing, or WGS, might be done. In WGS, researchers 
look at all of your genes and at almost all of your DNA. In “standard” genetic testing, 
researchers look at specific genes or subsets of genes, but not at all genes. Some 
possible genetic testing is described below. 
  


 
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For each of the questions below, choose the response that matches what you want by 
putting your initials in the space provided. Please ask the staff any questions that you 
have before you indicate your selections. 
  
Research Without Human Genetic Testing – OPTIONAL (Research on leftover blood; no 
human genetic testing) 
If you agree, some of your blood that is left over after all required study testing is done 
may be stored (with usual protection of your identity) and used for ACTG-approved HIV-
related research that does not include human genetic testing. 
 
____ (initials) I understand and I agree to this storage and possible use of my blood.  
 
OR 
____ (initials) I understand but I do not agree to this storage or possible use of my blood. 
 
Research With Human Genetic Testing – OPTIONAL (Human genetic research on leftover 
blood) 
If you agree, some of your blood that is left over after all required study testing is done 
may be stored (with usual protection of your identity) and used for ACTG-approved HIV-
related research that includes human genetic testing, and may include whole genome 
sequencing (WGS).  
 
____ (initials) I understand and I agree to this storage and possible use of my blood.  
 
OR 
____ (initials) I understand but I do not agree to this storage or possible use of my blood. 
 
Sharing Genetic Data - OPTIONAL  
Genetic Research Databases: If you agreed to possible genetic testing of your blood 
above, researchers may want to share genetic information (with protection of your 
identity) with other researchers around the world, so that they can learn more about the 
causes and treatment of diseases. They may store this information in dbGaP, a genetic 
database maintained by the National Institutes of Health, as well as in other protected 
databases. 
 
____ (initials) I understand and I agree to this possible sharing of my genetic data.  
 
OR 
____ (initials) I understand but I do not agree to this possible sharing of my genetic data. 
 
 


 
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WHAT IF I HAVE TO STOP TAKING BOTH STUDY-PROVIDED AND NON-STUDY-
PROVIDED ART?  
 
During the study:  
If you must stop taking ART for 7 or more days in a row before the week 24 study visit 
and you have not had an HIV-1 RNA test showing that your viral load was <50 copies/mL, 
then you will be asked to complete the discontinuation evaluations before having to stop 
the study medication and be taken off the study. The study staff will discuss other 
options that may be available to you. 
 
If you must stop taking ART for 7 or more days in a row either during the first 24 weeks after 
you have had HIV-1 viral load <50 copies/mL or after week 24 on Parts 1 and 2 of the 
study, or if you have two HIV-1 viral loads in a row that are >200 copies/mL at week 24 or 
after on Part 1, you will be asked by the study staff to return to the clinic to have a repeat HIV-1 
viral load test that will check whether your ART regimen is working. This test is called a virologic 
failure (VF) confirmatory test. If the confirmatory test results show that your ART regimen is 
working for you, then you will remain in the study for continued follow-up and no more PBMC 
and plasma collection and no optional procedures will be done after week 48 on Part 1 of the 
study. If the test results show that your ART regimen has failed, then you will be asked to 
complete the discontinuation evaluations before having to stop the study medication and being 
taken off the study. The study staff will discuss other options that may be available to you.  
 
After the study: 
After you have completed the study, the study will not provide you with study drugs. The study 
staff will talk with you about your choices. You and your doctor will decide what treatment you 
should have, and the study staff will discuss with you how you may be able to obtain ART after 
the study ends.  
 
 
WHAT ARE THE RISKS OF THE STUDY? 
 
The main risks of the procedures and study-provided drug are described below. 
 
Risks of Social Harm 
Although the study site will make every effort to protect your privacy and confidentiality, it is 
possible that other people could find out that you are in a study and this could cause problems 
for you. For example, other people might figure out that you are infected with HIV-1. If this 
happens, you could be treated unfairly or you could have problems being accepted by other 
family members, friends, and/or the community. 
 
Risks of Drawing Blood 
Taking blood may cause some discomfort, lightheadedness, bleeding, swelling, or bruising 
where the needle enters the body, and in rare cases, fainting or infection.  
 
Risks Related to Pregnancy 
The ART in this study may be unsafe for unborn babies. If you are having sex that could lead to 
pregnancy, you must agree not to become pregnant or to attempt to make a woman pregnant.  


 
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Because of the risk involved, you and your partner must use at least one effective method of 
birth control. You must continue to use birth control while receiving study drugs.  
 
Remember: If you are having sex, you need to use condoms to prevent transmitting your HIV-1 
infection to others.  
 
Approved methods of birth control are listed below. The study staff will talk with you about your 
choices. 
• 
Birth control medications that prevent pregnancy given as pills, shots, or placed on or under 
the skin  
• 
Male or female condoms with or without a cream or gel that kills sperm   
• 
Diaphragm or cervical cap with a cream or gel that kills sperm   
• 
Intrauterine device  
 
If you can become pregnant, you must have a pregnancy test, and the test result must be 
available at the study clinical research site before you can start ART. If you think you may be 
pregnant at any time during the study, you must tell the study staff right away. If you become 
pregnant during the study, you may choose to stay in the study [Sites: Please modify this 
language as necessary to comply with local/national guidelines]. The study staff will talk to you 
about your choices.  
 
If you become pregnant while on study, the study staff would like to obtain information 
from you about the outcome of the pregnancy (even if it is after your participation in the 
study ends). If you are taking anti-HIV drugs when you become pregnant, your pregnancy 
will be reported to an international database that collects information about pregnancies 
in women taking anti-HIV drugs. This report will not use your name or other information 
that could be used to identify you. 
 
Risks of ART  
All ART medications can have side effects. The drug regimen provided in this study may have 
side effects. Listed below are the more serious or common side effects that may be related to 
the study-provided drugs. Please note that these lists do not include all the side effects seen 
with the study-provided drugs. The staff will be able to tell you which are the most serious side 
effects. They will also be able to tell you what to do if you have any of these side effects. If you 
have questions concerning the additional study-provided drug side effects, please ask the 
medical staff at your site. 
 
BIC/FTC/TAF 
BIC/FTC/TAF (50/200/25 mg) is a fixed dose combination tablet containing three 
medications: bictegravir (BIC, B, GS-9883), emtricitabine (FTC, F), and tenofovir 
alafenamide (TAF). The safety information known about this tablet is from studies GS-
US-380-1489 and GS-US-380-1490, in which 634 patients who had never been treated for 
HIV received B/F/TAF (50/200/25 mg) for 96 weeks. Adverse drug reactions that have 
been identified are as follows: 
• 
Very common: headache, diarrhea, nausea.    
• 
Common: vomiting, abdominal pain, indigestion, passing gas, fatigue, and rash.    


 
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• 
Other adverse reactions: hives (urticaria) and swelling of the face, lips, tongue, or 
throat (angioedema). 
 
If you are living with hepatitis B virus (HBV), there is a possibility of an unexpected 
worsening of hepatitis B if you stop taking BIC/FTC/TAF.  
 
In a study in pregnant rats, a possible effect on the fertility of male and female baby rats 
born to mothers given BIC 300 mg/kg/day was observed. The decreases in fertility were 
slight and remained within the range seen in animals not given any drug in other studies. 
At the next lowest dose, 10 mg/kg/day, no effects were noted in the baby rats. At this 
dose, the mother’s BIC plasma exposure was approximately eight times higher than the 
estimated blood concentrations of BIC in humans when administered as BIC/FTC/TAF 
(50/200/25 mg).  
 
Please talk to your study doctor for more details on adverse events or see the 
BIC/FTC/TAF package insert for more information. 
 
Emtricitabine (FTC) 
The following side effects have been associated with the use of FTC: 
• 
Headache 
• 
Dizziness 
• 
Tiredness 
• 
Inability to sleep, unusual dreams 
• 
Loose or watery stools 
• 
Nausea or vomiting  
• 
Abdominal pain 
• 
Rash, itching, which sometimes can be a sign of an allergic reaction 
• 
Darkening of the skin on the palms of the hands and/or soles of the feet 
• 
Increased cough 
• 
Runny nose  
• 
Abnormal liver function tests, which could mean liver damage 
• 
Increases in pancreatic enzyme (a substance in the blood), which could mean a problem 
with the pancreas  
• 
Increased triglycerides (a type of fat found in the blood) 
• 
Increased creatine phosphokinase (a substance found in the blood), which could mean 
muscle damage 
 
NOTE: If you are infected with both hepatitis B and HIV-1, your liver function tests may increase 
and symptoms caused by hepatitis may get worse if you stop FTC. 
 
Lactic acidosis (elevated lactic acid levels in the blood) and severe hepatomegaly (enlarged 
liver) with steatosis (fatty liver) that may result in liver failure, other complications, or death have 
been reported with the use of antiretroviral nucleoside analogues, such as FTC, when used 
alone or in combination. The liver complications and death have been seen more often in 
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include: unexplained weight loss, stomach discomfort, nausea, vomiting, fatigue, cramps, 
muscle pain, weakness, dizziness, and shortness of breath.  
 
Some side effects of FTC may not need any medical attention. As your body gets used to the 
medicine, these side effects may disappear.  
 
Tenofovir Alafenamide (TAF) 
The following side effects have been associated with the use of TAF: 
• 
Nausea, vomiting, gas, loose or watery stools   
• 
Generalized weakness 
• 
Dizziness  
• 
Depression 
• 
Headache 
• 
Abdominal pain  
• 
Worsening or new kidney damage or failure 
• 
Inflammation or swelling and possible damage to the pancreas and liver 
• 
Shortness of breath  
• 
Rash  
• 
Allergic reaction: symptoms may include fever, rash, nausea, vomiting, loose or watery 
stools, abdominal pain, achiness, shortness of breath, a general feeling of illness, or a 
potentially serious swelling of the face, lips, and/or tongue 
• 
Bone pain and bone changes such as thinning and softening, which may increase the risk of 
breakage  
• 
Muscle pain and muscle weakness 
• 
Sleeping problems 
 
NOTES:  
• 
If you are infected with both hepatitis B and HIV-1, your liver function tests may increase 
and symptoms caused by hepatitis may get worse if you stop TAF.   
• 
Because there is only a small amount of information on TAF in pregnant and breastfeeding 
women, you should not use TAF during pregnancy or if breastfeeding. 
 
Lactic acidosis (elevated lactic acid levels in the blood) and severe hepatomegaly (enlarged 
liver) with steatosis (fatty liver) that may result in liver failure, other complications, or death have 
been reported with the use of antiretroviral nucleoside analogues, such as FTC, when used 
alone or in combination. The liver complications and death have been seen more often in 
women on these drug regimens. Some nonspecific symptoms that might indicate lactic acidosis 
include: unexplained weight loss, stomach discomfort, nausea, vomiting, fatigue, cramps, 
muscle pain, weakness, dizziness, and shortness of breath.  
 
Some side effects of TAF may not need any medical attention. As your body gets used to the 
medicine, these side effects may disappear.  
 
Cobicistat (COBI) 
The following side effects have been associated with the use of COBI: 
• 
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• 
Bloody urine 
• 
Chills 
• 
Clay-colored stools 
• 
Dark urine 
• 
Decreased frequency or amount of urine 
• 
Dizziness 
• 
Fast heartbeat 
• 
Fever 
• 
Headache 
• 
Hives or welts, itching, or rash 
• 
Hoarseness 
• 
Increased thirst 
• 
Irritability 
• 
Joint pain, stiffness, or swelling 
• 
Loss of appetite 
• 
Lower back or side pain 
• 
Nausea and vomiting 
• 
Pain in the groin or genitals 
• 
Redness of the skin 
• 
Sharp back pain just below the ribs 
• 
Swelling of the eyelids, face, lips, hands, lower legs, or feet 
• 
Tightness in the chest 
• 
Troubled breathing or swallowing 
• 
Unpleasant breath odor 
• 
Unusual tiredness or weakness 
• 
Vomiting of blood 
• 
Weight gain 
• 
Yellow eyes or skin 
• 
Dark-colored urine 
• 
Muscle cramps or spasms 
• 
Muscle pain or stiffness 
• 
Diarrhea 
• 
Discouragement 
• 
Feeling sad or empty 
• 
Irritability 
• 
Loss of interest or pleasure 
• 
Trouble concentrating 
• 
Trouble sleeping 
• 
Upper abdominal or stomach pain 
 
Some side effects of COBI may not need medical attention. As your body gets used to the 
medicine, these side effects may disappear.  
 


 
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Elvitegravir (EVG) 
The following side effects have been associated with the use of EVG: 
• 
Diarrhea 
• 
Headache 
• 
Nausea 
• 
Discouragement 
• 
Feeling sad or empty 
• 
Heartburn 
• 
Indigestion 
• 
Irritability 
• 
Lack of appetite 
• 
Loss of interest or pleasure 
• 
Rash 
• 
Stomach discomfort, upset, or pain 
• 
Thoughts or attempts at killing oneself 
• 
Trouble concentrating 
• 
Trouble sleeping 
• 
Unusual tiredness or weakness 
• 
Vomiting 
 
Some unwanted effects may be caused by EVG. In the event that any of these side effects do 
occur, they may require medical attention. Some of the side effects that can occur with EVG 
may not need medical attention. As your body adjusts to the medicine during treatment, these 
side effects may go away. Your health care professional may also be able to tell you about ways 
to reduce or prevent some of these side effects. If any of the aforementioned side effects 
continue, are bothersome, or if you have any questions about them, check with your health care 
professional. 
 
Some side effects of EVG may not need any medical attention. As your body gets used to the 
medicine, these side effects may disappear.  
 
Use of Combination Antiretroviral (ARV) Drugs 
In some people with advanced HIV-1 infection, symptoms from other infections or certain 
diseases may occur soon after starting combination ART but can also occur later.  Some of 
these symptoms may be life threatening. If you start having new symptoms, or notice that 
existing symptoms are getting worse after starting your ART, tell your health care provider right 
away. 
 
The use of potent ARV drug combinations may be associated with an abnormal placement of 
body fat and wasting. Some of the body changes include: 
• 
Increase in fat around the waist and stomach area 
• 
Increase in fat on the back of the neck 
• 
Thinning of the face, legs, and arms 
• 
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There is a risk of serious and/or life-threatening side effects when non-study-provided 
medications are taken with the study-provided drugs. For your safety, you must tell the study 
doctor or nurse about all medications you are taking before you start the study. It is also 
important that you do not start any new medications while on the study before discussing it with 
the study doctor or nurse. Also, you must tell the study doctor or nurse before enrolling in any 
other clinical trials while on this study. 
 
 
CAN I JOIN THE STUDY IF I AM CURRENTLY PREGNANT OR BREASTFEEDING? 
 
If you are pregnant or breastfeeding, you are allowed to take part in the study as long as you 
meet the requirements of the study. If you are pregnant at the time of enrollment, you will be 
instructed by the study staff to take alternative, non-study-provided ART during your pregnancy 
or while breastfeeding. 
 
 
WHAT IF I BECOME PREGNANT DURING THIS STUDY? 
 
If you become pregnant while on study, you must tell the study staff right away and see your 
doctor to get the best care possible. You will be asked to return to the clinic for a study visit at 
your earliest possible convenience. You may remain on study during your pregnancy or you 
may leave the study. Either way, the study staff will contact you to find out about any events that 
happen during your pregnancy and about the health of the baby. 
 
If you choose to stay in this study, you will not be able to continue on the study-provided drug. 
You and your study doctor will decide what ART are best for you now that you are pregnant. If 
you are on study-provided EVG/COBI/FTC/TAF or BIC/FTC/TAF, you will need to change to 
alternative non-study-provided ART that is felt to be appropriate for use in pregnancy by your 
study doctor and/or primary care provider. You will continue to have regularly scheduled study 
visits, but you will not take part in the optional procedures and large volume blood collection.   
This study will not provide care related to your pregnancy, the delivery of your baby, or the care 
of your baby. You must arrange for your care and your baby’s care outside of this study. Your 
study doctor will help you find appropriate care.  
 
Long-term follow-up is recommended for a baby whose mother takes ART during pregnancy. 
The study staff will talk with you about long-term follow-up and the possibility of enrolling your 
baby in a long-term follow-up study.   
 
After your baby is delivered, you may be able to return to the study-provided drug regimen you 
were taking before you became pregnant. It is unknown if the study-provided drugs pass 
through the breast milk and whether this may produce adverse effects in your baby. It is 
also unknown if taking the study-provided drugs will reduce the risk of passing HIV to 
your baby while breast feeding. If you decide to breastfeed your baby, you cannot remain on 
the study-provided drug regimen and must continue taking your current non-study-provided 
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WHY WOULD THE DOCTOR TAKE ME OFF THIS STUDY EARLY? 
 
The study doctor may need to take you off the study early without your permission if: 
• 
You never started ART (study-provided or non-study-provided drugs) or started ART later 
than 48 hours after joining the study. 
• 
An HIV-1 test shows that you are not infected with HIV or you have had HIV infection for a 
longer period of time than expected or your laboratory tests from entry show that you do not 
qualify for the study. 
• 
You miss 3 study visits in a row.  
• 
Your viral loads show that the HIV medications you are taking are no longer working well for 
you or if you have two viral loads in a row that are >200 copies/mL at week 24 or after 
on Part 1; this is known as having VF. 
• 
You stop taking ART for 7 days or more in a row, and you have not had a viral load 
<50 copies/mL (before stopping ART that lasted ≥7 days in a row) during Part 1. 
• 
Your doctor believes that remaining on the study is no longer what is best for you. 
• 
You are unable to follow the requirements of the study. 
• 
The study is stopped or cancelled. 
 
The study doctor may also need to take you off the study-provided drugs without your 
permission if: 
• 
Continuing the study-provided drugs may be harmful to you, for example, if the study drugs 
are making you sick. 
• 
You need a treatment that you may not take while on the study-provided drugs.  
• 
You become pregnant and/or start breastfeeding. 
 
If you must stop taking ART before the study is over or if you want to stop the study visits, then 
the study staff will ask you to return to the clinic for a final visit. 
 
If you are taken off the study early because you never started ART, you do not need to 
have a final visit. 
 
 
WHAT ARE THE BENEFITS OF BEING IN THIS STUDY? 
 
It is possible that being in this study will be of no direct benefit to you and that the optional 
procedures being done will not change your clinical care.  
 
It is also possible that being in this study benefits you in one of the following ways: 
• 
Gives you access to ART (for about 1 year).  
• 
Gives you more detailed information about your HIV-1 infection than you could get from your 
local anti-HIV care center; having this information could help you get better treatment for 
your HIV-1 infection. 
• 
Provides you with frequent health checks that could help identify problems early; having this 
information could help you get good treatment at the right time. 
 


 
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Finally, it is possible that your being in this study will provide information that will help others 
with HIV-1 infection. 
 
WHAT OTHER CHOICES DO I HAVE BESIDES THIS STUDY? 
 
Instead of being in this study, you have the choice of: 
• 
treatment with the anti-HIV drugs available to you locally 
• 
treatment with experimental drugs, if there is a study available locally for which 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. 
 
[Sites may insert general information about HIV/AIDS or other local study-specific treatment 
availability.] 
 
 
WHAT ABOUT CONFIDENTIALITY? 
 
For Sites in the US 
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 a Certificate of Confidentiality 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. Also, 
any publication of this study will not use your name or identify you personally.   
 
Your records may be reviewed by the ACTG, the US 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), National Institutes of Health (NIH), study staff, study 
monitors, drug companies 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 are 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 website will not include information that can identify you. At most, the website will 
include a summary of the results. You can search this website at any time.  
 
For Sites outside the US 
Efforts will be made to keep your personal information confidential. We cannot guarantee 
absolute confidentiality. Your personal information may be disclosed if required by law. Any 
publication of this study will not use your name or identify you personally. 
 


 
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Your records may be reviewed by the ACTG, the US 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) or Ethics Committee (a committee that 
protects the rights and safety of participants in research), National Institutes of Health (NIH), 
study staff, study monitors, drug companies supporting this study, and their designees.  
 
A description of this clinical trial will be available on www.ClinicalTrials.gov, as required by US 
law. This website will not include information that can identify you. At most, the Web site will 
include a summary of the results. You can search this website at any time.  
 
 
WHAT ARE THE COSTS TO ME? 
 
You will not have to pay for the study-provided drug, EVG/COBI/FTC/TAF or BIC/FTC/TAF. If 
your doctor decides that other drugs would work better for you, then you might have to pay for 
those drugs. This could happen if you are unable or unwilling to take EVG/COBI/FTC/TAF or 
BIC/FTC/TAF or if you become pregnant while on study.  
 
You will not have to pay for study visits, exams, and laboratory tests needed for this study. The 
study will perform one resistance test for all participants (at entry prior to taking the study 
medications) and possibly another resistance test in those participants whose ART regimen has 
failed (at the VF confirmatory visit). In addition, some of your blood may be tested at the end of 
the study to look at genetic factors. The results of these tests will not be available right away 
since the tests will be done later in the study.  
 
Taking part in this study may lead to added costs to you or your insurance company. In some 
cases, it is possible that your insurance company or health care system will not pay for these 
costs because you are taking part in a research study. [Sites: Delete references to insurance 
company or health care system if not applicable at site.] 
 
 
WILL I RECEIVE ANY PAYMENT? 
 
You will be reimbursed for the study visits and for the optional procedures done between weeks 
60 and 72 (such as gut biopsy and lumbar puncture). [Sites: If the participants will receive 
payment, describe the amount to be paid, the payment schedule and any prorated schedule 
should the subject decide to withdraw or is withdrawn early by the investigator.] 
 
 
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. [Sites: Please indicate whether this treatment will be provided free of charge, or 
whether the participant must pay the costs]. There is no program for compensation either 
through this institution or the NIH. You will not be giving up any of your legal rights by signing 
this consent form. 
 


 
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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. You will still be able to receive drugs to treat your HIV-1 infection outside 
this study. 
 
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 IRB or EC or other organization appropriate for the site. An 
IRB or EC is a group of people not connected with this study who will monitor the study at 
this site. 
• 
telephone number of above 
 
 


 
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SIGNATURE PAGE: A5354 INFORMED CONSENT 
 
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) 
 
 


 
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ATTACHMENT A: Study Visits 
 
The study staff can answer any questions you have about individual study visits, the evaluations 
that will occur, or how long each visit will be. The table below can be used as a quick reference 
for you, along with the explanations that follow. 
 
I. Study Schedule for Part 1 
 
Evaluation or Procedure 
Screening1 
Entry2 
Most Other 
Visits3 
Some 
Other 
Visits4 
Special 
Visit5 
Leaving or 
Stopping the Study 
Early6 
Consent 
 
 
 
 
 
 
Acute HIV-1 infection 
documented 
 
 
 
 
 
 
Medication history 
 
 
 
 
 
 
Medical history 
 
 
 
 
 
 
HIV-1 infection confirmed 
and Fiebig stage testing 
 
 
 
 
 
 
Group assigned and ART 
started 
 
 
 
 
 
 
Physical exam 
 
 
 
 
 
 
ART modifications 
 
 
 
 
 
 
Blood collected 
 
 
 
 
 
 
Pregnancy test 
 
 
If 
suspected 
 
 
 
Resistance test 
 
 
 
 
 
 
Urine collected 
 
 
 
 
 
 
Telephone follow-up with 
participants 
 
 
 
 
 
 
Adherence support 
 
 
 
 
 
 
Large volume blood draw  
 
 
 
 
 
 
Consent and Perform 
Optional procedures  
 
 
 
 
 
 
Approximate amount of 
blood 
 
up to 
359 
mL  
see 
footnote 3 
below for 
blood 
volume 
details 
see 
footnote 
4 below 
for blood 
volume 
details 
20 mL  
9 mL 
 
 


 
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II.  
Study Schedule for Part 2 
 
Evaluation or Procedure 
Step 2 
Entry2 
Every 24 
weeks 
until week 
1443 
Special 
Visit 5 
Leaving or 
Stopping the 
Study Early6 
Physical exam 
 
 
 
 
ART continued 
 
 
 
 
ART modifications 
 
 
 
 
Blood collected 
 
 
 
 
Pregnancy test 
 
If 
suspected 
 
 
Adherence support 
 
 
 
 
Approximate amount of 
blood 
up to 
83 mL  
up to 83 
mL/visit  
14 mL  
19 mL 
 
1Screening: After you have read and signed the consent form, the study staff will check your 
medical records for available documentation of your HIV-1 diagnosis; for instance, whether you 
are recently or acutely infected with HIV-1 to make sure that you meet the requirement for 
joining the study. You will be asked about anti-HIV and other kinds of medications you 
have taken in the past.  
  
2Entry Visit: If you are eligible to join the study, you will enter Part 1 of the study and be placed 
into a group. At the entry visit on Part 1 of the study, you will start taking ART. If you are 
unable or unwilling to take the study-provided drug, then you must have access to and can 
begin to take an alternative ART in order to enter the study.  
 
NOTE: In Part 1 of the study, large volume blood collection (about 320 mL of blood) will be 
done, and at some sites, optional leukapheresis may be done in place of large volume blood 
collection at entry.  
 
If you remain eligible after completing Part 1 of the study, you will enter Part 2 of the 
study. You will continue to take ART while on Part 2. If you are unable or unwilling to 
continue taking the study-provided drug, then you must have access to and can begin to 
taking an alternative ART in order to remain on the study. 
 
3Most Other Visits: Most participants will be seen at 1 week, 4 weeks, 12 weeks, and 24 weeks 
after entering the study and then at 48 weeks and thereafter at weeks 60 and 72. Those 
participants whose test results show Fiebig VI will have their final study visit at week 24 on Part 
1 of the study. Participants in Part 2 of the study will be seen every 24 weeks until week 
144.   
 
The approximate amount of blood (in mL) that will be drawn at study visits will be from 3 mL 
(or about 1 tsp) to 173 mL (or about 35 tsp). 
 


 
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4Some Other Visits: At weeks 2 and 8 (of Part 1) and the day after having the optional 
procedures (gut biopsy and/or lumbar puncture), you will be contacted by the study staff over 
the phone to check how you are doing. At week 36, you will come to the clinic to have a physical 
exam, a viral load test, and an adherence evaluation. 
 
At weeks 60 and 72, you will have blood drawn (23 mL or about 5 tsp) for routine safety labs at 
each visit. Depending on whether or not you reached the main goal of the study at week 48, you 
may be asked as to whether you are willing to have additional optional procedures done and 
samples collected between weeks 60 and 72 (see Appendix II for details on these procedures).  
 
5Special Visit: You may be asked to return for an extra visit at week 49 if you need to have 
blood drawn for an HIV test and other research tests. If it seems that the ART regimen is not 
working or if you are having side effects from your treatment regimen, then you may be asked to 
come to the clinic for an extra visit.  
 
6Leaving the Study Early: You will be asked to come to the clinic for an extra visit if you leave 
the study or stop the study treatment early.  
 
III. 
Explanation of Evaluations  
 
Consent and contact information collection  
After you read the consent and have had a chance to ask questions about the study, you will 
sign the consent form if you want to continue to be evaluated for study participation. You will 
also be asked how to be contacted in case you miss a visit or there are problems with your 
tests, and whether you give the study team permission to contact you. 
 
Acute HIV-1 infection documentation 
The study staff will check your medical records to see if you had an HIV test done as part of 
local routine care and whether you were recently or acutely infected with HIV-1.  
 
HIV-1 infection confirmation and Fiebig staging 
Blood will be collected to confirm that you have HIV-1 infection, and an additional blood sample 
will be collected for Fiebig staging (a test to show how far along you are with your HIV-1 
infection).  
 
Group assignment and study treatment/locally-provided ART 
You and the clinic staff will discuss your assigned group and the optimal ART options for you. 
These will be based on your acute HIV-1 diagnosis and medical history. At study entry, you will 
receive either study-provided or other non-study-provided ART based upon your discussion with 
the study site doctor. The study staff and the study pharmacist will tell you how often to take 
your drugs and whether you should take them with food. 
 
Physical examination 
You will have a physical exam and will be asked questions about your health and about any 
medicines you have taken or are taking now. You will also be asked about any symptoms 
and illness you may have had since the last visit.  
 


 
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ART modifications 
You will be asked if there has been any change in how you take your study-provided or 
non-study-provided anti-HIV medications since the last visit. 
 
ART continued 
In Step 2, you will be asked to confirm that you continue to take your study-provided or 
non-study-provided anti-HIV medications since the last visit. 
 
Blood collection  
Blood will be collected from you for various tests during the study. These include: routine safety 
laboratory tests, HIV-1 viral load (a test that shows how much HIV-1 is in your blood), CD4+ T-
cell count (a test that shows how many infection-fighting cells you have in your blood), and liver 
function tests.  
 
NOTE: For Part 2 of the study, laboratory tests, CD4+ T-cell count, and liver function 
tests may be collected from clinical records.  
 
At entry and at the confirmatory visit to check whether your ART regimen has failed, a sample 
will be collected for resistance testing (a test that shows whether the ART is working for you). 
Routine PBMC and plasma storage will be done.  
 
Human genetic testing  
Some of your blood will be tested to see whether the ART you are taking are making a 
difference by looking at your immune response (levels of infection fighting cells, CD4+ and 
CD8+ T-cells, in your blood) or whether development of resistance to ART is associated with 
different genes. You will not receive the results of these studies because they will be done in the 
future. 
 
Pregnancy testing  
If you are a woman who is able to become pregnant, then you may be asked to give a small 
urine or blood sample for a pregnancy test.  
 
HIV-1 resistance testing 
Your blood will be used to see which ART might work best for you. 
 
NOTE: If resistance testing was done as part of routine care, the study doctor may review these 
results to make sure that your current ART is still the best for you. 
 
Urine collection 
You will be asked to provide a small amount of urine that will be used in safety tests. 
 
Primary endpoint determination 
At week 48, you will be asked to give blood samples for testing to determine whether you met 
the main goal of the study by looking at the total amount of HIV genetic material in infection-
fighting cells at study week 48 (also known as the primary endpoint).  
 


 
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Site follow-up with participants via telephone  
You will be asked about how you have been feeling and how well you are remembering to take 
your ART.  
 
Adherence support 
Everyone will get some adherence support from the site staff. This means that the study staff 
will explain to you in detail how to take the medications and help you find ways to take the 
medications correctly. 


 
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ATTACHMENT B: SAMPLES COLLECTION AND OPTIONAL PROCEDURE  
AT STEP 1 ENTRY 
 
A. Explanation of Samples Collection and Optional Procedure 
 
The samples collection and optional procedure below will advance the scientific goals of this 
study but will offer no direct benefit to participants. Neither you nor your doctor will receive 
any results from the samples collection and optional procedure because these tests are for 
research purposes only. If you choose not to participate in the optional procedure, it will not 
affect your ability to take part in this study.   
 
NOTE: If you are pregnant, the samples collection and optional procedure will not be done. 
 
• 
Large volume blood collection  
 
A large volume blood draw (about 320 mL) will be collected.  
 
NOTE: At some sites, leukapheresis may be done in place of large volume blood 
collection. 
 
• 
Leukapheresis (in place of large volume blood draw) 
 
The leukapheresis procedure may be performed at [insert site-specific details]. The 
procedure will take about [insert site-specific details] and the full visit will last about 
[insert site-specific details]. You will have to remain in a semi-reclining or reclining 
position for most of this time. 
 
Leukapheresis is a medical procedure that involves removing whole blood from an 
individual/donor and separating the blood into individual components so that leukocytes 
(white blood cells) can be removed. The remaining blood components are then put back 
into the bloodstream of the individual/donor. This will be done by inserting a needle 
attached to sterile tubing in one arm, and first sending your blood through a machine. 
This machine spins your blood to separate the red blood cells (cells that carry oxygen), 
the white blood cells (cells that fight infection) and the platelets (cells that help form 
clots). The white blood cells will be kept for testing. The rest of your blood will be 
returned to your body through another needle and tube in your other arm. Not all of your 
white blood cells are removed, and your body will make more white cells within a few 
days. Losing the number of white blood cells that are collected does not pose a danger 
to your health. 
 
B. Risks Associated with Samples Collection and Optional Procedure 
 
• 
Large volume blood collection  
 
Taking blood may cause some discomfort, lightheadedness, bleeding, swelling, or 
bruising where the needle enters the body, and in rare cases, fainting or infection.  
 


 
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• 
Leukapheresis (in place of large volume blood draw) 
 
Leukapheresis has been shown to be safe in donors living with HIV and does not affect 
CD4+ T-cell count or immune status of short-term donors. The needle used is larger 
than normal blood draw and may be uncomfortable. Rarely, a participant may feel faint 
during or after leukapheresis. This sort of reaction can be handled by changing the 
participant’s position or administering intravenous fluids. You may experience chills, 
nausea, and heartburn caused by the citrate anticoagulant that is used during the 
procedure to keep the collected cells from clumping together in the bag. This chemical 
may use up some of the calcium in your blood stream, and tingling in the face, lips, or 
hands may be noted. If this happens, study staff may slow the rate of infusion of this 
chemical and may offer you one or two calcium carbonate tablets to correct the calcium 
loss. Participants will be observed closely by an experienced blood bank technician 
during the procedure.  
 


 
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APPENDIX II: CONSENT FOR OPTIONAL PROCEDURES AND SAMPLES COLLECTION 
AFTER WEEK 48 ON STEP 1 
 
If you met the main goal of the study (i.e., to look at the total amount of HIV genetic material in 
infection fighting cells at week 48), you may be asked and consented to take part in the optional 
procedures and samples collection that will be done between weeks 60 and 72. The optional 
procedures and samples collection (as described below) will advance the scientific goals of this 
study but will offer no direct benefit to participants. Neither you nor your doctor will receive any 
results from these procedures because these tests are for research purposes only. If you 
choose not to participate in the optional procedures, it will not affect your ability to take part in 
this study.   
 
NOTES:  
1. About 25 people participating in this study will take part in these optional procedures. 
2. If you are pregnant, these optional procedures and samples collection will not be done. If 
you stop taking ART for 7 days or more in a row or if you have a viral load that is 
confirmed to be more than or equal to 50 copies/mL, you will not be able to 
participate in these optional procedures.  
 
A. Explanation of Optional Procedures and Samples Collection 
 
• 
Gut biopsy 
 
The gut biopsy procedure will be performed at [insert site-specific details]. The 
procedure will take about [insert site-specific details], and the full visit should last about 
[insert site-specific details].    
 
A gut biopsy is a medical procedure that involves removing a sample of tissue taken 
from your gut to closely examine it. This will be performed following the local standards 
of care for this procedure. Just before the gut biopsy, you may have an enema (a salt 
water rinse that will flush out your lower bowel). Next, a lubricated flexible tube will be 
placed into your rectum. Using this instrument, the doctor will examine the inside of your 
intestine and will collect samples of tissue for testing.  
  
You should not have anal sexual intercourse for 3 days before and for 7 days after the 
procedure. The study or clinic staff will call you the day after the procedure to check on 
how you are feeling. 
 
[Note to sites: Insert details regarding how this procedure is performed in your institution 
and whether an additional consent form is required at the clinic where it will be 
performed]. 
 
• 
Lumbar puncture 
 
A lumbar puncture is a medical procedure that involves removing a small amount of 
cerebrospinal fluid (CSF) from your spine. You should drink plenty of fluids the day 


 
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before the lumbar puncture procedure. The procedure will be performed at [insert site-
specific details]. You will be asked to lie down on your side or to sit “backwards” in a 
chair (so that you are facing the back of the chair). An area of skin on your lower back 
will be sterilized with fluid. You will get an injection to numb the skin in the sterilized 
area. You may feel a burning sensation from the fluid that is injected. When the area is 
numb, the doctor will insert a thin needle between two of the bones in your spine. A 
small amount of fluid will be collected through the needle. The entire lumbar puncture 
procedure to this point will take about 30 minutes.  
 
After the CSF collection, you may be asked to lie flat for up to 30 minutes to reduce the 
chance that you will get a headache. You should limit your physical activity for the 
remainder of the day. The study or clinic staff will call you the day after the procedure to 
check on how you are feeling. 
 
B. Risks Associated with Optional Procedures and Samples Collection 
 
• 
Gut biopsy 
 
The preparation before the procedure may include taking laxatives or enema, which may 
be uncomfortable and may make participants feel weak from diarrhea. You may feel 
pressure or discomfort as the instrument (a lubricated flexible tube called a 
sigmoidoscope) is placed into your rectum as it passes through the curves of your colon 
during the procedure. You may receive medication throughout the procedure to reduce 
any discomfort. The doctor will put air into your colon in order to see the lining, and you 
may have some bloating or abdominal discomfort from the air. You may feel as though 
you need to have a bowel movement. You can pass the air if you feel the need. The 
doctor will remove as much air as possible after the procedure.  
 
There is a small risk (about 1/3,600) for bowel perforation which is a tear through the 
wall of the bowel that may allow leakage of bowel fluids. Perforations are generally 
treated with hospitalization, antibiotics, and possibly surgery. Bleeding can occur but 
usually will stop without treatment or can be controlled at the time of the procedure. 
Rarely, blood transfusions or other treatments may be required to stop the bleeding.  
 
After the procedure, you may feel dizzy or sleepy from the sleep and pain medicines. 
You should have someone come with you to accompany you home. You should not 
drive a car or a motorcycle. There is a small risk (less than 1/10,000) for a more severe 
allergic reaction to the sleeping medicine. 
 
• 
Lumbar puncture 
 
The risks of lumbar puncture include local soreness at the site of needle entry and pain 
and possible allergic reaction associated with local anesthesia. There is a small risk of 
headache or decreased blood pressure from removing the small amount of fluid or 
leaking of CSF after the procedure. There is a small risk of infection and a very small risk 
of damage to nerves in the lumbar spinal roots after the procedure, which could cause 
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the needle will be inserted will be cleaned with antiseptics (such as betadine or rubbing 
alcohol) in order to reduce the risk of infection. A bandage will be placed on the skin 
where the needle went in, and the participants will be asked to remove it the next day 
and tell the study doctor right away if any redness or tenderness is present. Participants 
will be asked to remain lying flat for up to 30 minutes after the procedure and will be 
given fluid to drink after the procedure. The site staff will ask the participants about 
history of any allergies to anesthetics and will not perform lumbar puncture in any 
participant with such history.  
 
Please indicate below if you agree to have any of these optional procedures and large volume 
blood collection done. No matter what you decide, it will not affect your participation in the study. 
You will not receive the results of these studies because they will be done in the future. You do 
not have to decide about the optional procedures and blood collection until week 48 of the 
study. 
 
Gut biopsy 
 
________ (initials) YES, I agree                     ________ (initials) NO, I do not agree 
 
 
Lumbar puncture 
 
________ (initials) YES, I agree                     ________ (initials) NO, I do not agree 
 
 
 
 


 
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SIGNATURE PAGE: A5354 INFORMED CONSENT FOR OPTIONAL PROCEDURES 
 
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 the optional procedures that will be done between 
weeks 60 and 72 on Part 1 of the 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)