Conditions: Vaginitis Trichomonal or Due to Trichomonas
Keywords: Trichomonas vaginalis metronidazole
Allocation: RANDOMIZED | Intervention model: PARALLEL
Enrollment: 623
Healthy volunteers: no

Brief summary:
The overall goal of this project is to determine the influence of patient treatment and host factors on repeat Trichomonas vaginalis (TV) infections among HIV-negative women

Detailed description:
This study is a phase III randomized clinical trial. HIV-negative women who test positive for TV at their routine gynecological exam at participating clinics will be referred to the nurse/study coordinator to screen for eligibility, provide a description of the study, and obtain written, informed consent (N=700). Subjects will undergo an audio computer assisted self- interview (ACASI), and will self-collect vaginal swabs for Trichomonas testing by InPouch and Nucleic Acid Amplification Test (NAAT), Gram stain testing, and a future microbiome specimen. They will be randomized into one of two arms; metronidazole (MTZ) 2 g single dose (CDC recommended treatment regimen) or MTZ 500 mg twice daily x 7-day dose (CDC alternative treatment regimen). All enrolled women will be scheduled for a follow-up visit at four weeks post treatment completion (window 3-13 weeks).

Arms:
arm 1: Single dose MTZ arm 2: Multi dose MTZ

Interventions: intervention 1: MTZ 500 mg twice daily x 7 days intervention 2: MTZ 2 g
Intervention descriptions: intervention 1: MTZ 500 mg twice daily x 7 days intervention 2: MTZ 2 g

Protocol document:
Prot_SAP_000.pdf: 
 
Version: 11.0 
Version date: 1/2/17 
 
 
 
 
Trichomonas vaginalis repeat infections among HIV-negative 
women 
 
 
NIAID Protocol Number: 12-0058 
 
Sponsored by:  
National Institute of Allergy and Infectious Diseases (NIAID) 
 
 
NIAID Funding Mechanism: TBA 
 
Pharmaceutical Support Provided by: N/A 
 
Other Identifying Numbers: 
 
IND Sponsor: N/A 
 
IND # 118276 
 
Principal Investigator/Protocol Chair: Patricia Kissinger, Ph.D. 
 
NIAID Medical Monitor: TBA 
 
Draft or Version Number: 11 
 
Day Month Year 
 
 2nd of January, 2017 
Confidentiality Statement 
 
This document is confidential and is to be distributed for review only to investigators, potential investigators, 
consultants, study staff, and applicable independent ethics committees or institutional review boards.  The 
contents of this document shall not be disclosed to others without written authorization from NIAID (or 
others, as applicable), unless it is necessary to obtain informed consent from potential study participants. 
 
 


Version: 11.0 
Version date:  1/2/17 
 
ii 
Statement of Compliance 
This trial will be conducted in compliance with the protocol and the Tulane University 
biomedical IRB. The Administrators of The Tulane Educational Fund through the Tulane 
University Biomedical IRB (FWA #00002055) is duly constituted, organized and 
operates in compliance with DHHS regulations as described in 45 CFR part 46, i.e. The 
Common Rule, FDA regulations as described in 21 CFR Parts 50 and 56.  Tulane’s 
Biomedical IRB also complies with the guidelines resulting from the International 
Conference on Harmonization (ICH) E-6 Good Clinical Practice guidelines as required 
to the extent required by third-party sponsors.  In addition, the Tulane University IRB 
operates in compliance with portions of the Health Insurance of Portability Act of 1996 
(HIPAA Privacy Rule) that apply to research, as described in 45 CFR Parts 160 and 164 
as appropriate. All investigators and staff will have completed the protection of Human 
Subjects Training as required by the participating institutions and will adhere to all 
NIAID Clinical Terms of Award. 


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iii 
Signature Page 1 
The signature below constitutes the approval of this protocol and the attachments, and provides 
the necessary assurances that this trial will be conducted according to all stipulations of the 
protocol, including all statements regarding confidentiality, and according to local legal and 
regulatory requirements and applicable U.S. federal regulations and ICH guidelines. 
The Lead Principal Investigator (Protocol Chair) should sign Signature Page 1.  A copy of this 
Signature Page 1 should be filed with the holder of the Regulatory documents and a copy 
should be maintained at the site. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


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iv 
Signature Page 2 
The signature below constitutes the approval of this protocol and the attachments, and provides 
the necessary assurances that this trial will be conducted according to all stipulations of the 
protocol, including all statements regarding confidentiality, and according to local legal and 
regulatory requirements and applicable U.S. federal regulations and ICH guidelines. The 
Investigator(s) of Record (signature(s) on 1572) from each participating clinical site should sign 
he Signature Page 2 as appropriate.  This Signature Page 2 should be maintained at each site 
 
  
 
 
 
 
 
 
 
 
 


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STATEMENT OF COMPLIANCE ...........................................................................................................................II 
SIGNATURE PAGE 1 ............................................................................................................................................. III 
SIGNATURE PAGE 2 ............................................................................................................................................. IV 
LIST OF ABBREVIATIONS ................................................................................................................................ VIII 
PROTOCOL SUMMARY .......................................................................................................................................... X 
1. 
KEY ROLES ....................................................................................................................................................... 1 
2. 
BACKGROUND INFORMATION AND SCIENTIFIC RATIONALE ........................................................... 5 
2.1 BACKGROUND INFORMATION ............................................................................................................................. 5 
2.1.1 
Description of the Study Agent(s)/Intervention(s) ............................................................................ 6 
2.1.2 
Summary of Previous Pre-clinical Studies ........................................................................................ 6 
2.1.3 
Summary of Relevant Clinical Studies ............................................................................................... 7 
2.1.4 
Summary of Epidemiological Data ..................................................................................................... 8 
2.2 RATIONALE ......................................................................................................................................................... 9 
2.3 POTENTIAL RISKS AND BENEFITS .................................................................................................................... 14 
2.3.1 Potential Risks ........................................................................................................................................ 14 
2.3.2 Potential Benefits ................................................................................................................................... 16 
3. 
STUDY OBJECTIVES..................................................................................................................................... 17 
3.1 PRIMARY OBJECTIVE........................................................................................................................................ 17 
3.2 SECONDARY OBJECTIVES ................................................................................................................................ 17 
3.3 EXPLORATORY OBJECTIVES ............................................................................................................................ 17 
4. 
STUDY DESIGN .............................................................................................................................................. 17 
4.1 DESCRIPTION OF THE STUDY DESIGN .............................................................................................................. 17 
4.2 STUDY ENDPOINTS ........................................................................................................................................... 18 
4.2.1 Primary Endpoint .................................................................................................................................... 18 
4.2.2 SECONDARY ENDPOINTS .............................................................................................................................. 18 
4.2.3 EXPLORATORY ENDPOINTS .......................................................................................................................... 18 
4.2.4 SUBSTUDY ENDPOINTS ................................................................................................................................. 18 
5. 
STUDY POPULATION .................................................................................................................................... 18 
5.1 DESCRIPTION OF THE STUDY POPULATION ..................................................................................................... 18 
5.1.1 
Participant Inclusion Criteria .............................................................................................................. 19 
5.1.2 
Participant Exclusion Criteria ............................................................................................................ 19 
5.2 STRATEGIES FOR RECRUITMENT AND RETENTION .......................................................................................... 19 
6. 
STUDY AGENT/INTERVENTIONS .............................................................................................................. 19 
6.1 STUDY AGENT ACQUISITION ............................................................................................................................ 20 
6.1.1 
STUDY AGENT/INTERVENTION # 1 -- Metronidazole ................................................................ 20 
6.1.1.1 Formulation, Packaging, and Labeling .......................................................................................................... 20 
6.1.2 
Co-enrollment Guidelines .................................................................................................................. 20 
6.1.3 
Preparation, Administration, Storage, and Dosage of Study Agent(s)/Intervention(s) ............. 20 
6.1.1.3 
Study Agent Accountability Procedures .................................................................................................. 20 
6.1.4 
STUDY AGENT/INTERVENTION #2 ............................................................................................... 21 
6.2 ASSESSMENT OF PARTICIPANT COMPLIANCE WITH STUDY AGENT(S)/INTERVENTION(S) ............................. 21 
6.3 CONCOMITANT MEDICATIONS AND PROCEDURES .......................................................................................... 21 
6.4 PRECAUTIONARY AND PROHIBITED MEDICATIONS AND PROCEDURES .......................................................... 21 
6.4.1 Prohibited Medications and Procedures ............................................................................................. 21 


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6.4.2 Precautionary Medications and Procedures ...................................................................................... 21 
6.5 PROPHYLACTIC MEDICATIONS AND PROCEDURES ......................................................................................... 22 
6.6 RESCUE MEDICATIONS ..................................................................................................................................... 22 
7. 
STUDY PROCEDURES/EVALUATIONS .................................................................................................... 22 
7.1 CLINICAL EVALUATIONS ................................................................................................................................... 22 
7.2 LABORATORY EVALUATIONS ........................................................................................................................... 23 
7.2.1 Clinical and Research Laboratory Evaluations and Specimen Collection ..................................... 23 
7.2.2 Specimen Preparation, Handling and Shipping ................................................................................. 23 
7.2.2.1 Instructions for Specimen Storage ................................................................................................................. 25 
7.2.2.2 Specimen Shipment Preparation, Handling and Storage ........................................................................... 25 
7.3 SUBSTUDIES ..................................................................................................................................................... 27 
8 
STUDY SCHEDULE ........................................................................................................................................ 27 
8.1 SCREENING ....................................................................................................................................................... 27 
8.2 ENROLLMENT/BASELINE .................................................................................................................................. 27 
8.3 FOLLOW-UP ...................................................................................................................................................... 29 
8.4 FINAL STUDY VISIT ........................................................................................................................................... 30 
8.5 EARLY TERMINATION VISIT .............................................................................................................................. 30 
8.6 PREGNANCY VISIT ............................................................................................................................................ 30 
8.7 UNSCHEDULED VISITS ...................................................................................................................................... 30 
9. 
ASSESSMENT OF SAFETY ......................................................................................................................... 31 
9.1 SPECIFICATION OF SAFETY PARAMETERS ...................................................................................................... 31 
9.2 DEFINITION OF AN ADVERSE EVENT (AE) ....................................................................................................... 32 
9.3 DEFINITION OF A SERIOUS ADVERSE EVENT (SAE) ....................................................................................... 32 
9.4 METHODS AND TIMING FOR ASSESSING, RECORDING, AND ANALYZING, MANAGING SAFETY PARAMETERS
 ................................................................................................................................................................... 32 
9.4.1 
Methods and Timing for Assessment .......................................................................................... 33 
9.4.1.1 
AE/SAE Grading and Relationship Assignment ............................................................................... 33 
9.4.2 
Recording/Documentation ............................................................................................................. 33 
9.4.3 
Analysis/Management ..................................................................................................................... 34 
Adverse events will be considered in the analysis of the endpoint in cases where they affect 
adherence to the drug. .................................................................................................................................... 34 
9.5.1 Specific Serious Adverse Event Requirements ........................................................................... 34 
9.6 
REPORTING OF PREGNANCY ..................................................................................................................... 35 
9.7 
TYPE AND DURATION OF THE FOLLOW-UP OF PARTICIPANTS AFTER ADVERSE EVENTS ....................... 35 
9.8 
MODIFICATION OF STUDY AGENT(S)/INTERVENTION(S) FOR A PARTICIPANT .......................................... 35 
9.8.1 
Dose / Schedule Modifications for a Participant ...................................................................... 36 
9.9 
HALTING RULES FOR THE PROTOCOL ...................................................................................................... 36 
9.10 
STOPPING RULES FOR AN INDIVIDUAL PARTICIPANT/COHORT ................................................................ 36 
9.11 
PREMATURE WITHDRAWAL OF A PARTICIPANT ........................................................................................ 37 
9.12 
REPLACEMENT OF A PARTICIPANT WHO DISCONTINUES STUDY TREATMENT ........................................ 37 
10.1 
SITE MONITORING PLAN ............................................................................................................................ 37 
10.2 
SAFETY MONITORING PLAN ...................................................................................................................... 37 
10.2.1  Safety Review Plan by the DSMB / SMC ..................................................................................... 38 


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11.  STATISTICAL CONSIDERATIONS ............................................................................................................. 38 
11.1 
OVERVIEW AND STUDY OBJECTIVES ........................................................................................................ 38 
11.2 
STUDY POPULATION .................................................................................................................................. 39 
11.3 
DESCRIPTION OF THE ANALYSES .............................................................................................................. 39 
11.4 
MEASURES TO MINIMIZE BIAS ................................................................................................................... 39 
11.5 
APPROPRIATE METHODS AND TIMING FOR ANALYZING OUTCOME MEASURES. .................................... 39 
11.6 
STUDY HYPOTHESES ................................................................................................................................. 40 
11.7 
SAMPLE SIZE ............................................................................................................................................. 40 
CONSIDERATIONS ................................................................................................................................................... 40 
11.8 
MAINTENANCE OF TRIAL TREATMENT RANDOMIZATION CODES ............................................................. 41 
11.9 
PARTICIPANT ENROLLMENT AND FOLLOW-UP ......................................................................................... 41 
11.10  PLANNED INTERIM ANALYSES ................................................................................................................... 42 
11.11  SAFETY REVIEW ........................................................................................................................................ 42 
11.12  IMMUNOGENICITY OR EFFICACY REVIEW .................................................................................................. 42 
11.13  FINAL ANALYSIS PLAN .............................................................................................................................. 42 
12.  QUALITY CONTROL AND QUALITY ASSURANCE ................................................................................ 44 
13.  ETHICS/PROTECTION OF HUMAN SUBJECTS ...................................................................................... 44 
13.1 INSTITUTIONAL REVIEW BOARD/ETHICS COMMITTEE ................................................................................... 44 
13.2 INFORMED CONSENT PROCESS ..................................................................................................................... 45 
13.2.1 Assent or Informed Consent Process (in Case of a Minor) ......................................................................... 45 
13.3 EXCLUSION OF WOMEN, MINORITIES, AND CHILDREN (SPECIAL POPULATIONS) ....................................... 45 
13.4 PARTICIPANT CONFIDENTIALITY .................................................................................................................... 46 
13.5 STUDY DISCONTINUATION .............................................................................................................................. 46 
14.  DATA HANDLING AND RECORD KEEPING ............................................................................................ 46 
14.1 DATA MANAGEMENT RESPONSIBILITIES ....................................................................................................... 46 
14.2 DATA CAPTURE METHODS ............................................................................................................................ 48 
14.3 TYPES OF DATA.............................................................................................................................................. 48 
14.4 SOURCE DOCUMENTS AND ACCESS TO SOURCE DATA/DOCUMENTS ......................................................... 48 
14.5 TIMING/REPORTS ........................................................................................................................................... 49 
14.6 STUDY RECORDS RETENTION ........................................................................................................................ 49 
14.7 PROTOCOL DEVIATIONS ................................................................................................................................. 49 
15.  PUBLICATION POLICY ................................................................................................................................. 50 
16.  SCIENTIFIC REFERENCES .......................................................................................................................... 52 
SITE ROSTER .......................................................................................................................................................... 61 


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List of Abbreviations 
 
AE 
Adverse Event/Adverse Experience 
ACASI 
Audio/Computer Assisted Survey Instrument 
BV 
Bacterial vaginosis 
CC 
CrescentCare Health and Wellness Center 
CDC 
Centers for Disease Control and Prevention 
CFR 
Code of Federal Regulations 
CIB 
Clinical Investigator’s Brochure 
CRF 
Case Report Form 
DCC 
Data Coordinating Center 
DOT 
Directly observed therapy 
DSMB 
Data and Safety Monitoring Board 
DSMC 
Data and Safety Monitoring Committee 
FDA 
Food and Drug Administration 
FMS 
Future microbiota study 
FWA 
Federal-Wide Assurance 
GCP 
Good Clinical Practice 
HIPAA 
Health Insurance Portability and Accountability Act 
IB 
Investigator’s Brochure 
ICF 
Informed Consent Form 
ICH 
International Conference on Harmonization 
IDE 
Investigational Device Exemption 
IEC 
Independent or Institutional Ethics Committee 
IND 
Investigational New Drug 
IRB 
Institutional Review Board 
ISM 
Independent Safety Monitor 
JCHD 
Jefferson County Department of Health 
LSUHSC 
Louisiana State University Health Sciences Center 
MSDH 
Mississippi Department of Health 
MTZ 
metronidazole 
NAAT 
Nucleic acid amplification test 
NYU 
New York University 
N 
Number (typically refers to participants) 
NDA 
New Drug Application 
NIAID 
National Institute of Allergy and Infectious Diseases, NIH 
NIH 
National Institutes of Health 
OHRP 
Office for Human Research Protections 
OHSR 
Office for Human Subjects Research 


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List of Abbreviations 
PCR 
Polymerase Chain Reaction 
PHI 
Protected Health Information 
PI 
Principal Investigator 
QA 
Quality Assurance 
QC 
Quality Control 
SAE 
Serious Adverse Event/Serious Adverse Experience 
SOP 
Standard Operating Procedure 
TOC 
Test of Cure 
TV 
Trichomonas vaginalis 
UAB 
University of Alabama at Birmingham 
UMMC 
University of Mississippi Medical Center 
 
 
 
 
 


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Protocol Summary 
 
 
Full Title 
Trichomonas vaginalis repeat infections among HIV-negative women.  
Short Title 
TV repeat infections among HIV- women 
Clinical Trial 
Phase 
III 
IND Sponsor (if 
applicable) 
118276 
Conducted By 
Tulane University School of Public Health and Tropical Medicine 
Principal 
Investigator 
 
Patricia Kissinger, Ph.D. 
Sample Size 
1664 
Study Population 
HIV negative women who are TV positive and are the age of majority, 
English speaking, not pregnant or breast feeding, and are patients at 
participating clinics; 95% of participants are anticipated to be African 
American. 
Accrual Period 
30 months 
Study Design 
This study is a phase III randomized clinical trial examining two different 
doses of metronidazole (MTZ) for the treatment of Trichomonas 
vaginalis (TV). HIV negative women who test positive for TV at their 
routine exam at participating clinics will be referred to the nurse/study 
coordinator who will screen for eligibility, provide a description of the 
study, and obtain written, informed consent (N=1664). Subjects will 
undergo an audio computer assisted self-interview (ACASI), and will 
self-collect up to 4 vaginal swabs for InPouch culture and nucleic acid 
amplification test (NAAT) for TV, Gram stain for bacterial vaginosis 
(BV) and storage for future microbiota studies (FMS). Subjects will then 
be randomized into one of two arms: (1) metronidazole (MTZ) 2 g 
single oral dose (CDC recommended treatment regimen) or (2) MTZ 
500 mg oral dose BID for 7 days (CDC alternative treatment regimen) 
Participants will be scheduled for a Test of Cure (TOC) follow up visit 4 
weeks after treatment completion with a window of 3-12 weeks post-
baseline for the 2 gm MTZ dose and 4-13 weeks post-baseline for the 7 
day MTZ dose.  If a woman is NAAT TV+/InPouch TV- at TOC, she 
may be asked to return for an additional follow up at 4 weeks post TOC 
visit (window of 3-8 weeks post TOC visit). During follow up visits 


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subjects will undergo ACASI and self-collect up to 5 vaginal swabs for 
TV and BV testing and FMS. 
Study Duration 
Participants will be enrolled in the study for the time it takes to complete 
their follow up visits (no more than 21 weeks). Accrual for the study will 
be 30 months in duration.  Participants will be asked for permission to 
store their samples for future research and for investigators to use their 
data for secondary data analyses. 
Study 
Agent/Intervention 
Description 
Metronidazole 2g single oral dose under direct observation and 
Metronidazole 500 mg oral dose BID for 7 days with the first dose 
given under direct observation  
 
Primary Objective 
 
To examine the influence of two factors on repeat infections with TV 
among HIV negative women:  dosing and the presence of bacterial 
vaginosis (BV):  
We will test two hypotheses: 
H1: Women receiving multi-day MTZ will be less likely to test TV 
positive at TOC compared to women who receive the single dose MTZ. 
 
H2:  This effect (H1) will only be observed among women who have BV 
(Nugent score > 7). 
Secondary 
Objectives 
To determine the proportion of infections at follow up that are 
attributable to treatment failure or sexual re-exposure. 
Exploratory 
Objectives 
Examination of the rate and factors associated with adherence to 
medication, knowledge/belief/factors associated with partner treatment, 
sexual exposure and the nature of the sexual act and sexual partner, 
and condom use will be possible using the ACASI survey data. These 
factors will be assessed by arm to determine if any confounding 
occurred and if so, these analyses will be adjusted for these factors. 
These data will also help inform future translational research.  
Endpoints 
Repeat infection with Trichomonas vaginalis (TV) at 4 weeks (TOC) as 
measured by InPouch culture or NAAT. 
 
 
 
 
 
 
 
 


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Schematic of Study Design Showing Projected Enrollment:   
 
 
 
TV+ Women 
(N=2,702)
Figure 1.   
Randomization Scheme 
Eligible TV+ Women 
(N=2,080) 77%
In-eligible/un-locatable 
TV+ Women 
(N=622) 23%
Eligible/Accept Women 
(N=1664) 80%
Eligible/Refuse Women 
(N=416) 20%
Single-dose 
(N=832) 
Multi-dose
(N=832)
Single-dose complete FU
(N=666) 80% 
Multi-dose complete FU
(N=666) 80%
LTFU (N=166) 
LTFU (N=166) 


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1. KEY ROLES 
For questions regarding this protocol, contact:  
Dr. Hagit David 
Product Development Program Officer 
Sexually Transmitted Infections Branch 
DMID/NIAID/NIH/DHHS Room 5026 
6610 Rockledge Drive 
Bethesda, MD 20892-6604 
A.  Required Elements: 
 
Institutions:  
Sponsor:  
Tulane University School of Public Health and Tropical Medicine 
 
Department of Epidemiology 
 
1440 Canal St, New Orleans, LA 70112  
 
Contact Person: Dr. Patricia Kissinger 
 
Phone: (504)988-7320 
 
Fax: (504)988-1568 
 
kissing@tulane.edu 
 
Clinic study sites:   
 
CrescentCare Health and Wellness Center 
3308 Tulane Avenue, New Orleans, LA 70119 
Contact Person: Dr.  Rebecca Lillis 
Phone: (504) 207-2273 
Fax: (504) 568-2416 
rlilli@lsuhsc.edu 
 
Crossroads Clinic 
350 W Woodrow Wilson Drive Jackson, MS 39213 
Contact Person: Dr. Leandro Mena 
Phone: (601) 987-6728 
Fax: (601) 987-6729 
lmena@umc.edu 
 
Jefferson County Department of Health - STD Specialty Clinic 
1400 6th Avenue South 
Birmingham, AL 35233 
Contact Person: Dr. Christina Muzny 
Phone: (205) 975-3298 


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Fax: (205) 975-7764 
cmuzny@uab.edu 
 
Individuals: Principal Investigator: Patricia Kissinger, Ph.D., Professor 
Tulane University School of Public Health and Tropical Medicine 
Department of Epidemiology  
1440 Canal Street, Suite 2004 
New Orleans, LA. 70112 
Phone: (504) 988-7320 
Fax: (504) 988-1568 
kissing@tulane.edu 
 
Medical Co-Investigator: David H. Martin, M.D. 
Tulane University School of Public Health and Tropical Medicine 
Department of Epidemiology 
1440 Canal Street, Suite 2006 
New Orleans, LA 70112 
Phone: (504) 568-5031 
Fax: (504) 988-1568 
dmarti6@tulane.edu 
 
Biostatistical Co-Investigator:  Leann Myers, PhD, Professor 
Tulane University School of Public Health and Tropical Medicine 
Department of Biostatistics and Bioinformatics  
1440 Canal Street, Suite 2031 
New Orleans, LA. 70112 
Phone: (504) 988-7855 
Fax: (504) 988-1706. 
myersl@tulane.edu 
 
Site Principal Investigator: Rebecca Lilllis, MD, Assistant Professor,  
3308 Tulane Avenue  
New Orleans, LA 70119 
Phone: (504) 207-2273 
Fax: (504) 568-2416 
rlilli@lsuhsc.edu  
 
Site Co-Investigator: Stephanie Taylor, MD,   Professor 
3308 Tulane Avenue  
New Orleans, LA 70119 
Phone: (504) 207-2273 
Fax: (504) 568-2416 
staylo2@lsuhsc.edu 


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Site Principal Investigator: Leandro Mena, MPH, MD, Associate Professor  
University of Mississippi Medical Center 
Division of Infectious Diseases 
2500 N. State Street 
Jackson, MS. 39216 
Phone: (601) 984-5560 
Fax: (601) 815-4014 
lmena@umc.edu 
 
Site Principal Investigator: Christina Muzny, MD, Assistant Professor 
University of Alabama at Birmingham 
Division of Infectious Diseases 
1802 6th Av S.   
Birmingham, AL 39233 
Phone: (205) 975-3298 
Fax: (205) 975-7764  
cmuzny@uab.edu 
 
Site co-investigator: Jane Schwebke, MD, Professor 
University of Alabama at Birmingham 
Division of Infectious Diseases 
1802 6th Av S.   
Birmingham, AL 39233 
Phone: (205) 975-5665 
Fax: (205) 975-7764  
schwebke@uab.edu 
 
Site co-investigator: Jane Carlton, PhD, Director, Professor  
New York University 
Department of Biology 
Center for Genomics and Systems Biology 
12 Waverly Pl 
New York, NY 10003 
Phone: (212) 992-6981 
Fax: (212) 992-9532 
jane.carlton@nyu.edu 
 
 
 


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Project Manager: Norine Schmidt, MPH 
Tulane University School of Public Health and Tropical Medicine 
Department of Epidemiology 
1440 Canal Street, Suite 2006 
New Orleans, LA 70112 
Phone: (504) 988-8268 
Fax: (504) 988-1568 
nschmid1@tulane.edu 


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5 
2. BACKGROUND INFORMATION AND SCIENTIFIC 
RATIONALE 
2.1 Background Information 
Trichomonas vaginalis (TV), the most common curable sexually transmitted infection (STI) in 
the world1, is associated with vaginitis, cervicitis, urethritis, low birth weight, preterm delivery2, 
pelvic inflammatory disease3 and may increase the risk of HSV and HIV acquisition4-7 and 
transmission8-10.  Repeat infections are common, ranging from 5%-31%11-20, and share similar 
sequelae to primary infections. Determining the origin of these repeat infections and examining 
better treatment options is the focus of this study.  
     Potential causes of early repeat TV infections include: drug resistance, non-adherence to 
treatment, clinical treatment failure, or re-infection. Single dose therapy has removed adherence 
as an issue and vitro resistance testing has consistently demonstrated low rates of 
insusceptibility. The most likely sources of repeat infections, therefore, are clinical treatment 
failure (dosing or host factors) or re-infection from an untreated partner.  
     In our study of TV-infected women who were given directly observed single dose 
metronidazole (MTZ) and provided with medication to deliver to their sex partner(s), repeat 
infections rates were high (8%) and nearly all (92%) were attributed to clinical treatment 
failure11.  Clinical treatment failure could be due to insufficient dosing or biological factors that 
interfere with antibiotic treatment.   The Centers for Disease Control and Prevention (CDC) 
guidelines for treatment of TV include: MTZ or tinidazole 2 g single dose as the recommended 
regimens, and MTZ 500 mg BID 7 day dose as the alternative treatment regimen21.  These 
recommendations, however, were based on studies conducted nearly 30 years ago and while 
single dose was found to be equivalent to multiple dose therapies, repeat TV infection rates 
after single dose treatment were high (i.e. 5-20%). We recently completed a randomized 
controlled trial (RCT) among HIV-infected women with TV and found multi-dose MTZ to be 
superior to single dose treatment22. We also found that the presence of bacterial vaginosis (BV) 
was likely a major factor in the early failure of the single dose treatment.  Whether these findings 
can be extrapolated to HIV-negative women will be examined in aims 1 and 2.   
    Re-infection from an untreated partner is another potential source of repeat infections. Since 
TV testing for men is difficult and many TV infected men are asymptomatic23, partner treatment 
is paramount to reducing repeat infections. Patient-delivered partner treatment (PDPT), or the 
provision of antibiotics to infected index persons to deliver to their sex partners, is a possible 
alternative to the standard of partner referral (PR) or telling the index woman to refer her partner 
for care.  While PDPT has been found to be superior to standard partner referral methods for 
reducing repeat Chlamydia and gonorrhea infections24, RCTs of PDPT for TV have found 
conflicting results13-25 and, to date, the CDC has not made recommendations to offer PDPT for 
TV infected women.  However, these studies were single centered and likely underpowered, 
thus larger multi-centered trials are needed.   
          Given the high prevalence of TV, the absence of a national screening program, the 
deleterious reproductive outcomes associated with TV and the potential for a TV infection to 


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increase HIV transmission, reducing repeat TV infections is an important targeted public health 
approach.  The overall goal of this project is to determine the influence of index treatment and 
host factors on repeat TV infections among HIV-negative women in two specific aims:  
 
     Aim 1: Index treatment- Multi-dose (7 day 500 mg BID - alternative regimen) vs. single 
dose (2 g – recommended regimen) of MTZ for the treatment of TV.   
     Aim 2: Host factors - To determine if altered vaginal flora, as measured by Nugent 
score, interferes with TV treatment.  
 
         These aims will be accomplished by conducting a phase III randomized clinical trial among 
TV infected HIV negative women (N=1664) attending clinics in New Orleans, LA, Birmingham, 
AL or Jackson, MS.  These public clinics serve mostly African American, low income women, 
the demographic group most highly affected by TV26.  Women will be randomized to a single 
dose or multi-dose arm.  Test of cure will be conducted at 4 weeks post treatment completion.  .  
Viable vaginal specimens from women who are TV+ at TOC will undergo MTZ susceptibility 
testing and TV genotyping (to compare baseline and follow-up types).  Self-collected specimens 
from women who provide specific consent will be stored for future microbiome studies of the 
vaginal flora and other related studies. The information obtained from this study will be used to 
refine treatment recommendations and to better understand the origins of repeat TV infections. 
Given the strong multi-centered, RCT design, and the large sample size, results should rapidly 
inform treatment guidelines thus having high impact.  
 
The ultimate goal is improved reproductive health for women, particularly minority 
women, and the reduction of the potential for HIV transmission, fitting well with NIAID’s 
mission.  
 
 
2.1.1 Description of the Study Agent(s)/Intervention(s) 
This is an RCT to examine two doses of MTZ: 
 
MTZ 2 g single dose - (CDC recommended treatment regimen) Following randomization, 
women assigned to the single dose arm will be given the 2 g oral dose of MTZ under direct 
observation.  
MTZ 500 mg BID 7-day dose - (CDC alternative treatment regimen) Following 
randomization, women assigned to the 7 day arm will be given the 500 mg oral dose BID for 7 
days with the first dose given under direct observation. 
 
2.1.2 Summary of Previous Pre-clinical Studies  
N/A 
 
 
 
 
 


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2.1.3 Summary of Relevant Clinical Studies 
.  
     Single versus multi-dose MTZ - In the 1970’s and 80’s, studies were published which 
support switching from the standard treatment of MTZ 250 mg TID 7 day dose to a single, high-
dose treatment regimen for TV. In 1972, Woodcock et al, using microscopy to diagnose TV, 
conducted a non-randomized comparison of women treated with MTZ 2 g single dose to women 
treated with MTZ 200 mg TID for 7 days. After 4 weeks, results showed roughly twice as many 
repeat infections in the trial group as in the control group with respective repeat infection rates 
of 12.3% (9/73) and 6.7% (4/60) p-value not reported16. The authors concluded that the single 
dose was “acceptable treatment” for TV. Another early study by Csonka in 1971, which also 
used microscopy to diagnose TV, but used a randomized design compared patients who were 
randomly given the MTZ 2 g single dose to patients given the MTZ 200 mg TID 7 day dose. 
Women were followed for 3 months, and possible cases of re-infection were excluded. The 
repeat infection rates due to probable treatment failure were 18% (7/36) for the single dose 
group and 6% (3/49) for the 7 day group27. The authors report that the cure rates were not 
statistically different (p=0.06) and thus the two doses were equivalent, though they were not 
powered for an equivalency trial. The authors concluded that the MTZ single dose treatment “is 
a practical and acceptable alternative to the longer conventional course”27. In 1982, Aubert and 
Sesta reported results from their study comparing the MTZ 2 g single dose to the 250 mg TID 7 
day dose, where women from a family planning clinic were diagnosed with TV by wet mount 
preparation and offered the option of single vs. 7 day dose treatment. At the follow-up visit, 
which occurred 7 to 21 days post-treatment, women were tested for TV using wet mount 
preparation. The repeat infection rates were similar (6.2% (6/96) for the single dose vs. 2.7% 
(2/74) for the 7 day dose, p=0.47)28 but there are potential major biases due to the fact that 
women were allowed to self-select their treatment option. 
     In the above mentioned comparison studies, the repeat TV infection rates were nearly 
double for the MTZ single dose groups versus the 7 day dose groups. However, given the small 
sample sizes, the differences were not found to be statistically significant.  The authors propose 
a move towards the MTZ single dose treatment because of the advantage of observing the 
patient take the single dose treatment16,28, the practicality and simplicity of the single dose 
treatment27, the classic therapeutic dictum to treat using the lowest effective dose28, and cost 
savings28.  
     There were other early randomized, double-blind evaluations comparing single dose MTZ to 
multiple-dose regimens that found closer results. In 1979, Thin et al. reported results from their 
randomized, double blind comparison of the MTZ 2 g single dose versus the MTZ 400 mg BID 5 
day dose. Women were diagnosed with TV by wet preparation and culture, and were asked to 
return 7 and 14 days after the start of treatment. The repeat TV infection rates were similar for 
both groups after 14 days of follow-up (7.7% (4/52) for single dose vs. 7.6% (5/66) for 5 day 
dose)17, however, there was significant loss to follow-up (39%).  In 1980, Hager et al. reported 
their results from a randomized, double-blind evaluation of the MTZ 2 g single dose versus the 
MTZ 250 mg TID 7 day dose. Women were also diagnosed with TV by wet mount preparation 
and culture, and asked to return in 14 days (range of 7-21 days after treatment). This study was 


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plagued by a low follow-up rate with only 37.6% of the women returning for a study visit 
(176/468) and the repeat TV infection rates were as follows: 14.0% (13/93) in the single dose 
group and 8.4% in the 7 day group, p>0.10)18.   In sum, the data to support the use of single 
dose MTZ is not strong and prior studies have several methodological concerns indicating that 
the proper dose of MTZ merits further investigation.  
 
2.1.4 Summary of Epidemiological Data 
 
Epidemiology  - TV is the most common curable STI among women both worldwide and in the 
US29.  In the U.S. there are approximately 7 million new cases of TV each year30 and 
prevalence rates range from 3% in a nationally representative sample of women26, to 14% in 
adolescents31, 13-36% in pregnant women32-33,  11-26% in women attending STD clinics34-37, 
27% among an urban, inner-city population38, 38% among drug users39, and up to 47% in newly 
incarcerated pregnant women40.  The highest prevalence of TV infection in US women is seen 
among African-Americans with rates ranging from 13-51%41.  Despite the high rate of TV in both 
the general and selected sub-populations, there is no screening program in the US for TV.  And 
since over 80% of cases can be asymptomatic42 most TV infections likely go undetected. 
 
Sequelae of TV - Studies show an 
association between TV and vaginitis, 
cervicitis, urethritis, bacterial vaginosis, 
candidiasis, herpes simplex virus type-1 
and type-2, Chlamydia, gonorrhea, and 
syphilis7,40,42-45.  TV has also been 
associated with poor birth outcomes 
such as low birth weight, preterm 
delivery, pelvic inflammatory disease3,46-
48, and premature rupture of 
membranes2,49-50.   A recent study also 
showed an association between 
maternal TV infection and intellectual 
disability in children51. Although rare, TV 
infection can be transmitted perinatally52 
and cause vaginal and respiratory 
infections in neonates53-54. Treatment during the prenatal period is controversial given found 
deleterious effects55-56. Therefore, effective and successful treatment of TV is imperative during 
the preconception phase and is important for reducing TV-associated morbidities and improving 
the general health status of women. 
     But the most compelling reason to study and control TV: it may amplify the risk of HIV 
acquisition4-6 and transmission8-9.   Cross-sectional42,57-59 and prospective studies4-6 have shown 
an association between TV infection in women and HIV acquisition. This greater susceptibility is 
biologically plausible for three reasons:  inflammatory response to TV infection results in the 
Figure 2. Hypothetical level of HIV transmission 
attributable to T. vaginalis at varying prevalences  
of TV infection79


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appearance of HIV target cells60-61; TV infection can cause punctate mucosal hemorrhages 
resulting in a compromised mechanical barrier to HIV62; and TV infection may change the 
normal vaginal flora and therefore increase susceptibility to bacterial vaginosis63, which would 
increase the risk of HIV acquisition64.  These consequences combine to enlarge the portal of 
entry for HIV in TV-infected women.   A study by Sorvillo et al. estimates that in a community 
with a TV prevalence of 25%, as much as 20% of HIV could be attributed to TV infection65.  
Also, a recent study estimates that 6.2% of all HIV infections among US women may be 
attributable to TV infection66. Control of TV, therefore, may provide a cost-effective strategy for 
reducing HIV transmission especially in settings where TV is common67-68 or among subgroups 
who are at higher risk for TV such as African Americans69. In the absence of a national 
screening program to detect primary infections, reducing repeat TV infections can be a targeted 
approach for reducing TV transmission and TV-related morbidity.   
Repeat TV infections – Repeat TV infections are common, ranging from 5%-31%11-20, and 
share similar sequelae to primary infections. While it is clear that the TV repeat infection rate is 
unacceptably high, the source of these repeat infections is less clear.  Possible sources are 
drug resistance, host resistance, or sexual exposure (either by an untreated original partner or a 
newly acquired sex partner). In our preliminary work, we found evidence that a large proportion 
of the repeat infections could be attributed to treatment failure (i.e. no sexual exposure and no 
drug resistance).  In the data described in Table 1, of 301 HIV-negative women who were 
treated for TV with the MTZ 2 g single dose, 8.0% (n=24) retested positive for TV at one month 
post-treatment. Of the 24 repeat infections, 92% (n=22) were categorized as probable treatment 
failures using sexual histories11. From the 22 women with probable treatment failure, only 2 
(9.0%) had strains with moderate resistance to MTZ and 1 (4.5%) had a strain with mild 
resistance.  All three responded 
to higher doses of MTZ.  
Reported rates of MTZ resistance 
among mostly non-HIV infected 
women range from 2.2-9.6% 31,70-
72 and were usually resolved with 
repeat MTZ treatment at the same 
or higher dosage72. Therefore, 
resistance appears to play only a 
minor role in explaining probable 
treatment failure 
 
2.2 Rationale  
 
RATIONAL AIM 1:  
Single versus multi-dose MTZ - In the 1970’s and 80’s, studies were published which 
supported switching from the standard treatment of MTZ 250 mg TID 7 day dose to a single, 
high-dose treatment regimen for TV. In 1972, Woodcock et al, using microscopy to diagnose 
Table 1.   No. (%) of patients with a second test result positive for 
               Trichomonas vaginalis  after treatment with metronidazole. 


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TV, conducted a non-randomized comparison of women treated with MTZ 2 g single dose to 
women treated with MTZ 200 mg TID for 7 days. After 4 weeks, results showed roughly twice as 
many repeat infections in the trial group as in the control group with respective repeat infection 
rates of 12.3% (9/73) and 6.7% (4/60) p-value not reported16. The authors concluded that the 
single dose was “acceptable treatment” for TV. Another early study by Csonka in 1971, which 
also used microscopy to diagnose TV, but used a randomized design compared patients who 
were randomly given the MTZ 2 g single dose to patients given the MTZ 200 mg TID 7 day 
dose. Women were followed for 3 months, and possible cases of re-infection were excluded. 
The repeat infection rates due to probable treatment failure were 18% (7/36) for the single dose 
group and 6% (3/49) for the 7 day group27. The authors report that the cure rates were not 
statistically different (p=0.06) and thus the two doses were equivalent, though they were not 
powered for an equivalency trial. The authors also concluded that the MTZ single dose 
treatment “is a practical and acceptable alternative to the longer conventional course”27. In 
1982, Aubert and Sesta reported results from their study comparing the MTZ 2 g single dose to 
the 250 mg TID 7 day dose, where women from a family planning clinic were diagnosed with TV 
by wet mount preparation and offered the option of single vs. 7 day dose treatment. At the 
follow-up visit which occurred 7 to 21 days post-treatment, women were tested for TV using wet 
mount preparation. The repeat infection rates were similar (6.2% (6/96) for the single dose vs. 
2.7% (2/74) for the 7 day dose, p=0.47)28 but there are potential major biases due to the fact 
that women were allowed to self-select their treatment option. 
     In the above mentioned comparison studies, the repeat TV infection rates were nearly 
double for the MTZ single dose groups versus the 7 day dose groups. However, given the small 
sample sizes, the differences were not found to be statistically significant. From the authors’ 
comments, there seemed to be a desirability to move towards the MTZ single dose treatment 
because of the advantage of observing the patient take the single dose treatment16,28, the 
practicality and simplicity of the single dose treatment27, the classic therapeutic dictum to treat 
using the lowest effective dose28, and cost savings28.  
     There were other early randomized, double-blind evaluations comparing single dose MTZ to 
multiple-dose regimens that found closer results. In 1979, Thin et al. reported results from their 
randomized, double blind comparison of the MTZ 2 g single dose versus the MTZ 400 mg BID 5 
day dose. Women were diagnosed with TV by wet preparation and culture, and were asked to 
return 7 and 14 days after the start of treatment. The repeat TV infection rates were similar for 
both groups after 14 days of follow-up (7.7% (4/52) for single dose vs. 7.6% (5/66) for 5 day 
dose)17, however, there was significant loss to follow-up (39%).  In 1980, Hager et al. reported 
their results from a randomized, double-blind evaluation of the MTZ 2 g single dose versus the 
MTZ 250 mg TID 7 day dose. Women were also diagnosed with TV by wet mount preparation 
and culture, and asked to return in 14 days (range of 7-21 days after treatment). This study was 
plagued by a low follow-up rate with only 37.6% of the women returning for a study visit 
(176/468) and the repeat TV infection rates were as follows:  14.0% (13/93) in the single dose 
group and 8.4% in the 7 day group, p>0.10)18.   In sum, the data to support the use of single 
dose MTZ is not strong and prior studies have several methodological concerns indicating that 
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Other nitroimidazoles – It should be noted that tinidazole (TDZ), which is from the same 
class of drugs as MTZ, is also considered first line therapy by CDC as a 2 gram single 
dose.  A meta-analysis of treatment for TV found that MTZ had significantly higher rates of 
treatment failure, clinical failure, and side effects compared to TDZ, though the only blinded 
study included in this analysis did not show any advantages for TDZ73. This drug has not shown 
superiority over MTZ for the treatment of bacterial vaginosis74.  It can be argued that since TDZ 
is at least as good for TV infection as MTZ and may be better, that we should use this drug 
rather than MTZ for this trial.  While TDZ has become generic, the price difference (generic TDZ 
is 3 times more costly) is likely to make TDZ cost prohibitive as a front line medication,  Thus, 
public health clinics around the world will likely continue to use MTZ for TV infections for many 
years into the future.   Future trials may also 
wish to include TDZ.  
 
RATIONALE AIM 2 
TV treatment among HIV+ women.  Prompted 
by our prior work and others who found that 
post-treatment repeat TV infection rates among 
HIV-positive ranged from 18-36%11,76-77, we 
examined potential causes of this high repeat 
infection rate.  The purpose of the study was to 
determine if the single dose MTZ 
(recommended) is as effective as the multi-dose (alternative) for treatment of Trichomonas 
vaginalis (TV) among HIV+ women. Using a Phase IV randomized clinical trial, HIV-positive 
women with culture confirmed TV were randomized to treatment arm:  MTZ 2 g single dose or 
MTZ 500 mg BID 7 day dose. All women were given 2 g MTZ doses to deliver to their sex 
partners. Women were re-cultured for TV at a test-of-cure (TOC) visit occurring 6-12 days after 
treatment completion. TV-negative women at TOC were re-cultured at a 3 month visit. Repeat 
TV infection rates were compared between arms. Of the 270 HIV+/TV+ women who were 
enrolled, the mean age was 40 years, ± 9.4 and 92.2% African-American. Treatment arms were 
similar with respect to age, race, CD4 count, viral load, ART status, site, and loss-to-follow up.  
Women in the 7 day arm had: lower repeat TV infection rates at TOC [8.5% (11/130) versus 
16.8% (21/125) (R.R. 0.50, 95% CI=0.25, 1.00; p<0.05)], compared to the single dose arm.  
Because of the known potential for false negatives with TOC culture, we also examined the 
effect at 3 months and found that the superiority of the approach persisted [3 months [11.0% 
(8/73) versus 24.1% (19/79) (R.R. 0.46, 95% CI=0.21, 0.98; p=0.03)].  We concluded that the 7 
day MTZ dose was more effective than the single dose for the treatment of TV among HIV+ 
women.  (Table 2). 
 
Altered flora, bacterial vaginosis and TV - One possible factor in the treatment failure of TV is 
vaginal flora disturbances. Bacterial vaginosis (BV) is the most common vaginal condition in 
women of childbearing age78. The prevalence of BV in the US ranges from 29% in a nationally 
Table 2.  T. vaginalis results by Metronidazole Treatment 
Arm at Test-of-Cure (n=255) and 3 month (n=152) 


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representative sample (where the prevalence was 3.1 times greater for African-American 
women compared to whites)79,  44% in a group of women at high-risk for HIV78, and as high as 
56% among injection drug users79. Like TV, BV can also increase a woman’s susceptibility to 
HIV infection64,82-83. Several studies have shown a strong association between TV and BV33,84-86, 
meaning that the two frequently occur as co-infections among women. While these two vaginal 
infections have similar 
symptomatology and are treated 
with similar medication, the 
dosing is not the same. The 
Centers for Disease Control and 
Prevention (CDC) guidelines for 
treatment of TV include: MTZ or 
TDZ 2 g single dose as the 
recommended regimens, and 
MTZ 500 mg BID 7 day dose as 
the alternative treatment 
regimen21.  For BV, the first line of 
therapy is 500 mg MTZ BID for 7 
days.  Thus, the first line of 
therapy for TV would not adequately treat concomitant BV.    
     In a screening study of HIV-positive women, we found that the prevalence of TV was higher 
among women who had altered vaginal flora (Table 3) and that the majority (61.0%) of 
HIV+/TV+ women also had BV87.  This high rate of BV that accompanies TV infection among 
HIV+ women has implications for treatment decisions.  
     These findings prompted us to re-examine the data from our RCT where we found multi-
dose MTZ to be superior to single dose to see if BV had any influence on treatment outcomes. 
In analyses, stratified by treatment arm, we found that among women given single-dose 
treatment, those with TV/BV co-infection were 4.2 times more likely to retest TV-positive at TOC 
than those with baseline TV infection only.  This difference was not among women given the 
multi-dose and was not observed for either dose at 3 months (Table 4) 88.  
Table 3.  Distribution of T. vaginalis according to Nugent Score 
categories and association between vaginal flora and T. vaginalis 
infections among HIV-positive women (n=356) 


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     These data suggest that the vaginal 
environment associated with BV at the time 
of TV treatment in some way partially 
protects the organism (TV) from the effects 
of single-dose MTZ but over a more 
prolonged period of time the effect is largely 
lost.  The influence of the vaginal 
environment on TV treatment has been 
alluded to in other studies.  Over 40 years 
ago, Nicol et al.89 reported the possibility 
that inactivation of MTZ might be the cause 
of multiple treatment failures in a woman 
infected with a TV strain that was susceptible to the drug in vitro. A few years later, McFadzean 
et al.90 described inactivation of MTZ by bacteria isolated from 16 samples taken from 84 
women with TV vaginitis. Ten of the organisms were Gram-positive cocci including 7 cases of 
Streptococcus (Enterococcus) faecalis. The six others were Gram negative rods including 
Escherichia coli, Proteus spp. and Klebsiella spp.  More recently, several papers have reported 
that various members of the genus Enterococcus are capable of inactivating MTZ91-93.  Deep 
sequencing studies have not found many of these organisms in patients with BV94-96 but it could 
be that even minor populations of certain organisms or combinations of organisms may have 
the ability to inactivate MTZ clinically.   
     Martin et al. found that TV prevalence was highest in the women with intermediate Nugent 
scores (fig. 3) confirming the observations of Hillier et al97 and Gatski88.  A heat map analysis of 
on pyrosequencing data showed that the vaginal flora of 18/30 TV + women had a similar 
unique microbiota characterized by high abundance of Mycoplasma ssp or Ureaplasma ssp. 
and relatively low abundance of Lactobaccilus spp. and Gardnerella spp98 suggesting that TV 
directly influences microbial environment and confirms the potential importance of interactions 
between TV and vaginal microbiota.  
  Our findings show that BV has no effect on TV treatment outcome in women taking the 7 day 
course of MTZ treatment, the recommended dose for BV, clearly implying that drug inactivation 
by BV flora is not complete.  In our previous studies, we proposed that MTZ treatment induces a 
state of latency in TV to the extent that many treatment failures are not detectable by culture 
shortly following treatment but are detectable after longer time intervals22,99.  As the effect of BV 
on MTZ treatment outcome is only manifested soon after treatment there must be other 
mechanisms such as intrinsic relative resistance to MTZ in play to explain the fact that BV is not 
significantly associated with late single dose treatment failures.  Whether BV influences TV 
treatment outcomes among HIV-negative women is unknown and will be explored in aim 2. In 
the preliminary work, we did not measure BV at the follow-up visits, so we could not determine if 
resolution of BV improves treatment effect of multi-dose MTZ.  This present study will measure 
BV at all visits to determine if the BV was resolved and compare the effects of resolved and 
unresolved BV on TV treatment. 
 
Figure 3.  TV prevalence by Nugent Score 


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2.3 Potential Risks and Benefits 
Every measure will be taken to protect the rights of subjects, protect confidentiality, and minimize 
the risk. 
 
2.3.1 Potential Risks 
Participants will be recruited from the patients receiving care at participating clinics. Because of 
the nature of the study, very personal information regarding sexual behaviors and STIs will be 
collected. The potential risk for these subjects fall into three categories: psychological risk, 
confidentiality risk, and physical safety risks. 
 
Psychological risk – Many of the questions are highly personal in nature (e.g. sexual activity, 
substance use). These questions could evoke feelings of embarrassment, anxiety, fear or 
remorse. Through the biological testing, the participant could discover that they have an STI or 
are pregnant. There is also a potential that these biological tests could have a false positive or 
false negative result. 
 
Protection against psychological risk - The participants will be told that they are not required to 
be in the study to receive a clinical exam and STI testing and/or treatment as per standard 
clinical protocols. Each clinical site will provide these services as part of their standard of care. A 
response of “refuse to answer” will be included on all survey questions. Participants will be told 
that she may choose not to answer any questions that make her feel uncomfortable. All surveys 
will take place in a private setting. Clinical protocols will be followed in case of a positive culture 
result at follow-up visits; therefore she will receive counseling and treatment as per typical clinic 
visit. Participants will be counseled that not every biological test is 100% accurate but the tests 
used for this study have very low error rate. If the participant needs further counseling, clinical 
protocols will be followed to refer her to a mental health counselor, social worker or other 
specialist. 
 
Confidentiality risk –The interviews and surveys will elicit information on sexual behaviors and 
partnerships. They may feel vulnerable to breach of confidentiality answering personal questions 
about themselves and their partners. Contact information will be collected in order to conduct 
follow-up visits. 
 
Protection against confidentiality risk –  
 
A Certificate of Confidentiality has been obtained from the Food and Drug 
Administration.  This can be utilized to legally refuse to disclose information that may 
identify participants in any federal, state, or local civil, criminal, administrative, legislative, 
or other proceedings, for example, if there is a court subpoena.  When possible, this 
certificate will be utilized to resist any demands for information that would identify 
participants.  The Certificate cannot be used to resist demand for information from 


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personnel of the United States Government that is used for auditing or evaluation of 
federally funded projects or for information that must be disclosed in order to meet the 
requirements of the federal Food and Drug Administration (FDA).  
 
Databases are housed on Tulane’s HIPAA compliant servers. Access to these 
databases is password protected and is limited to authorized personnel (including select 
site staff, the Lead PI and the Tulane staff who handle data). All authorized personnel 
have undergone training in the handling of confidential data and have signed a 
confidentiality form.   
 
Survey data are temporarily located on site computers that are encrypted and password 
protected and are only accessed by authorized site personnel. These computers are 
provided by the study and are encrypted and maintained by Tulane’s Informational 
Technology staff. Survey data is transferred to Tulane at least weekly after which Tulane 
staff confirms receipt of the data and requests that the data is deleted from the site 
computers.  Data deletion is confirmed by communication between Tulane staff and the 
site staff who transferred the data and is checked at the next data transfer by Tulane 
staff. On site visits, confirmation that no data is stored on site computers is confirmed by 
the person conducting the site visit. Site computers are secured kept in a locked space 
when not in use. 
 
Any contact information collected by the interviewers will only be accessible to study staff 
at the site where it was collected, the Principal Investigator and authorized study staff at 
Tulane University. Once the study follow-ups are completed or the participant is 
considered lost to follow-up, their contact information is archived on a password 
protected computer in a password protected database at the Tulane study office in case 
of need to contact participants.  
 
Original paper contact forms and CRFs are kept in study folders at the sites along with 
the signed consent forms and are stored in secure file cabinets. Copies of CRFs are kept 
at Tulane University in secured cabinets. 
 
Physical risk - Women may have some discomfort during her specimen collection; they may also 
be at risk for abuse if she discloses her TV status to the partner. The MTZ multi dose is not 
approved by the FDA for treatment of TV; however, it is a commonly used medical dose and is 
listed as an alternate treatment for non-pregnant and non-lactating women in STD treatment 
guidelines from the Centers for Disease Control and Prevention (CDC) 
[http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6403a1.htm]. Women may suffer increased side 
effects or adverse reactions from this dose. Metronidazole is a Class B medication that has 
been used safely in the first trimester of pregnancy but pregnancy outcomes have not been 
systematically described in prior studies and thus remain contraindicated for use in the first 
trimester as per the final product label. If a pregnant woman tests negative for pregnancy at 
enrollment and takes metronidazole there is a potential for danger to the fetus. If a subject 
becomes pregnant while in this study, the clinician may request permission to follow her during 
the pregnancy and to follow her child after delivery to document any possible adverse outcomes 
of exposure during pregnancy. Breast feeding women will not be enrolled in the study, however, 


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if a woman does not disclose that she is breast feeding and enrolls, the medication may pass 
through her breast milk to her nursing child and there is a potential for metronidazole-related 
medical problems with that child. 
 
Protection against physical risk - For the specimen collection, women will be instructed on proper 
collection techniques and will collect specimens in a private and clean room which will be 
maintained at a comfortable temperature. Women will be counseled about the investigational 
dose provided and potential side effects and adverse reactions will be described. Participants 
will be advised to contact their provider if any such events occur. At any time a woman wishes to 
discontinue participation in the study, she may with no consequences to her primary health care. 
For the danger of abuse from a sexual partner, women will be reminded that if they feel that any 
of their partners will have such a reaction, they should not tell them about her TV infection; she 
will also be referred to additional counseling as needed per clinic protocol.  
 
Pregnancy and breastfeeding are exclusion criteria. Women of child bearing potential who have 
not been tested for pregnancy during her clinic visit on the day of enrollment will be tested for 
pregnancy by study staff (post-consent and pre-randomization) to ensure that she is not 
pregnant. Women who have had a hysterectomy or are post-menopausal for at least two years 
will not be required to take a pregnancy test. Staff will ask women about their breast feeding 
status prior to enrollment. Any woman who is breast feeding will not be eligible for the study. 
Women will be advised to use two forms of birth control while taking study medications. 
 
2.3.2 Potential Benefits 
There are a few benefits. The potential benefit to the woman is that she will be receiving more 
intensive follow-up of her TV infection.  She will also have the opportunity to have her specimen 
tested for drug resistance (which is not routinely done at the clinic). 
 
Information from this research study will be used to improve treatment options for TV-positive 
women. Given the high prevalence of TV, the absence of a national screening program, the 
deleterious reproductive outcomes associated with TV and the potential for a TV infection to 
increase HIV transmission, reducing repeat TV infections is an important targeted public health 
approach. The overall goal of this project is to determine the influence of index treatment and 
host factors on repeat TV infections among HIV-negative women in two specific objectives. The 
ultimate goal is improved reproductive health for women, particularly minority women, and the 
reduction of the potential for HIV transmission, fitting well with NIAID’s mission.  


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3. STUDY OBJECTIVES 
3.1 Primary Objective 
 
1. To determine if women receiving multi-day MTZ will be less likely to test TV positive at 
TOC compared to women who receive the single dose MTZ. 
2. To examine if this effect (H1) will only be observed among women who have BV (Nugent 
score > 7). 
 
3.2 Secondary Objectives 
 
To determine more precisely the origin of a TOC positive result using the results of the 
genotyping and the sexual histories and to determine if most of the infections are treatment 
failure, re-exposure, sexual exposure to a new partner or organism lack of susceptibility to MTZ.  
 
3.3 Exploratory Objectives 
 
Examination of self-reported adherence to medication, subject knowledge of partner treatment, 
sexual exposure and the nature of the sexual act and sexual partnering, and condom use will be 
possible using the ACASI survey data. These factors will be assessed by arm to determine if 
any confounding occurred and if so, these analyses will be adjusted for these factors. 
 
4. STUDY DESIGN 
 
4.1 Description of the Study Design 
 
To achieve the 2 aims, we will conduct a phase III randomized clinical trial among TV infected 
HIV-negative women (N=1664) attending clinics in New Orleans, LA, Birmingham, AL and 
Jackson, MS.  These public clinics serve mostly African American, low income women, the 
demographic group most highly affected by TV26.  Informed by our prior RCTs, women will be 
randomized to a single dose or multi-dose arm.  Test of cure will be conducted at 4 weeks post 
treatment completion. If at TOC, a subject is NAAT TV+/InPouch TV- she may be asked to 
come back 4 weeks post TOC for an 8 week follow up.  Viable specimens of women who are 
TV+ at TOC will undergo MTZ susceptibility testing and TV genotyping (to compare baseline 
and follow-up types).  A baseline, TOC, and 8 week follow up specimen will be stored for future 
microbiome studies of the vaginal flora for women who consent to long term specimen storage 
and use. The information obtained from this study will be used to refine treatment 
recommendations for TV.   Given the strong multi-centered, RCT design, and the large sample 
size, results should rapidly inform treatment guidelines thus having high impact. The follow-up 
survey and specimen collection will be repeated for those who return for an 8-week follow-up 
visit. 
 


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4.2 Study Endpoints 
 
4.2.1 Primary Endpoint 
The primary endpoint for both aims is a TV infection identified by culture or NAAT at the TOC 
visit.  
4.2.2 Secondary 
Endpoints 
The study is powered for repeat 
infections.  Since we will have information 
on sexual exposure and genotyping, we 
can also refine this outcome measure to 
examine treatment failure (H1 & H2) and 
will use the algorithm depicted in figure 4. 
 
 
4.2.3 
Exploratory Endpoints 
 
Examination of index adherence to medication, index knowledge of partner treatment, sexual 
exposure and the nature of sexual acts and sexual partners, and condom use will be possible 
using the ACASI survey data. These factors will be assessed by arm to determine if any 
confounding occurred and if so, these analyses will be adjusted for these factors or stratified by 
these factors. 
 
4.2.4 Substudy Endpoints  
N/A 
 
 
5. STUDY POPULATION 
 
        5.1 Description of the Study Population 
 
TV-positive women (N=1664) will be enrolled from three sites, Crossroads Clinic in Jackson, MS, 
STD Specialty Clinic in Birmingham, AL and CrescentCare Health and Wellness Center and  in 
Figure 4: Algorithm for 
determining origin of repeat 
infection at TOC 


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New Orleans, LA. Approximately 95% of the clinics’ populations are African American. Potential 
participants will be patients at the sites who have tested positive for TV by standard clinical 
screening during their routine clinic appointment and who meet the inclusion/exclusion criteria. 
 
5.1.1 Participant Inclusion Criteria 
To be eligible for the study, all subjects must meet the following inclusion criteria: female; 
English speaking; age of majority; test TV positive during their clinical visit; have the ability to 
agree to refrain from all alcohol use for 24 hours after taking oral MTZ; be willing to take MTZ 
treatment; and be willing to be randomized to either arm of the study.  
 
5.1.2 Participant Exclusion Criteria 
 
Subjects who meet any of the following exclusion criteria will not be able to participate in the 
study: HIV-infected; pregnant, breast feeding; treated by their provider for BV at visit; previously 
enrolled in the study; incarcerated; have medical contraindications to MTZ (such as currently 
taking disulfiram, alcoholism or known liver damage, taking anticoagulants/blood thinners); have 
been treated with any meds used to treat TV or BV including MTZ, tinidazole, seconidazole, 
acetarsol, boric acid, furazolidone, and paromomycin within the previous 14 days; unable or 
unwilling to provide informed consent; unwilling to return for a follow-up visit 4 weeks post 
treatment completion (3-13 weeks post treatment completion).  
 
5.2 Strategies for Recruitment and Retention 
 
Women who are TV positive per clinical screenings will be referred to study staff by their clinical 
providers. Eligibility criteria will be reviewed by study staff and informed consent obtained. 
During consent, follow up visits will be described to the participant. At baseline, detailed subject 
contact information and preferred methods of contact will be obtained and reviewed. Study staff 
will remind participants of their follow up visits via text messages, email, phone calls, or mail 
depending on the preference of the participants. If a participant misses her scheduled follow up 
appointment, study staff will contact her to reschedule. 
 
Prior to their follow up visits, women will be contacted by study staff via their preferred method 
(i.e., cell phone, text message, email) as a reminder.  If they miss their scheduled visit, study 
staff will attempt contact at least five times to reschedule. In our prior research, we found that 
95% of women have either daily internet or text messaging use, so these methods of enhancing 
follow-up will be used if patients prefer them.  All contact attempts will be noted in the 
participant’s file. At follow up visit, contact information and preferred methods of contact will be 
updated in the case that the TOC specimens are positive.   
 
 
6. STUDY AGENT/INTERVENTIONS 
 


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6.1 Study Agent Acquisition 
 
6.1.1 STUDY AGENT/INTERVENTION # 1 -- Metronidazole 
 
6.1.1.1 Formulation, Packaging, and Labeling 
 
Generic MTZ will be provided on site at all clinics. Treatment will be given by the study provider 
(RN, NP, MD). Medication that is not consumed in the clinic will be in containers with child-proof 
caps, labeled with dose, instructions, and contact information for the clinic and the study 
personnel. Also warning labels will be on the container (for multi-dose) which will instruct users 
to refrain from alcohol consumption and to not take if there are known allergies to MTZ. 
Subjects receiving the single dose will be provided the information verbally. Participant dose will 
be determined at randomization. Half of the women (n=832) will be randomized to receive the 
single dose and the other half (n=832) will be randomized to receive the 7 day dose. 
MTZ 2 g single oral dose - (CDC recommended treatment regimen) Following randomization, 
women assigned to the single dose arm will be given the 2 g oral dose of MTZ under direct 
observation. If for any reason a participant is unable to take the medication DOT, this will be 
recorded in their study chart and adherence questions will be asked at the follow up visit.  
MTZ 500 mg oral dose BID for 7 days - (CDC alternative treatment regimen) Following 
randomization, women assigned to the 7 day arm will be given the 500 mg oral dose BID for 7 
days with the first dose given under direct observation. If for any reason a participant is unable 
to take the first dose DOT, this will be recorded in their study chart and adherence questions will 
be asked at the follow up visit. 
 
6.1.2 Co-enrollment Guidelines 
Participants of this study are eligible to co-enroll in any other studies being conducted at the 
clinical sites during their enrollment in this study excluding studies that require treatment with 
metronidazole. 
 
6.1.3 Preparation, Administration, Storage, and Dosage of Study 
Agent(s)/Intervention(s) 
Metronidazole will be stored at room temperature and protected from light. Doses will be 
packaged at the clinic by approved pharmacists/clinicians. Expiration dates will be noted and 
inventory checked by study coordinators and lot numbers will be documented. This is not a 
blinded study therefore no placebo pills will be given to women in the single dose arm. 
6.1.1.3 Study Agent Accountability Procedures 
 
Metronidazole for the study will be obtained by the investigators following approved guidelines 
at each clinical site. Each site will follow a pharmacy plan that is approved by their institutional 
IRB(s) and acknowledged by Tulane IRB. Metronidazole will be stored at room temperature, 
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approved pharmacy plans. An inventory of all medication received and distributed will be 
maintained by the study coordinator/nurse.  
 
 
6.1.4 STUDY AGENT/INTERVENTION #2   
N/A 
 
 
6.2 Assessment of Participant Compliance with Study 
Agent(s)/Intervention(s)  
Participants randomized to the single dose of MTZ will be asked to take their medication at the 
clinic under direct observation. If there are any complications taking the medication, it will be 
noted on her study folder.   
Those randomized in the 7 day arm will be asked to take their first dose under direct 
observation at the clinic and instructed to take the additional doses over the following six days.   
At the follow up visits, participants will be asked to report adherence to medication on their 
ACASI surveys.  
 
 
6.3 Concomitant Medications and Procedures 
 
We will capture concomitant medications and co-occurring STIs at baseline on the CRF when 
this information is available.  
 
 
6.4 Precautionary and Prohibited Medications and Procedures 
 
6.4.1 Prohibited Medications and Procedures  
 
None 
 
6.4.2 Precautionary Medications and Procedures 
 
If the participant was not tested for pregnancy during her clinical visit and she is of child bearing 
potential, she will be tested by study staff after consent and pre-randomization to ensure that 
she is not pregnant. Women who have had a hysterectomy or are post-menopausal for at least 
two years will not have pregnancy testing. If it is determined that an enrolled participant is 
pregnant per her study pregnancy test, she will receive her baseline compensation and be 
administratively withdrawn from the study. These women will not receive a study ID number. 
Participants will be advised that alcohol should be avoided because metronidazole and alcohol 
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can increase the blood thinning effects of warfarin (Coumadin) and increase the risk of bleeding 
probably by reducing the breakdown of warfarin. Cimetidine (Tagamet) increases blood levels of 
metronidazole while cholestyramine reduces blood levels of metronidazole by reducing its 
absorption. Metronidazole blocks the breakdown of propylene glycol in the liver leading to 
accumulation of propylene glycol in blood. Accumulation of propylene glycol could cause 
seizures, increased heart rate, and lead to kidney failure. Metronidazole increases the blood 
levels of carbamazepine (Tegretol, Tegretol XR, Equetro, Carbatrol), lithium (Eskalith, Lithobid) 
and cyclosporine though unknown mechanisms. Serious reactions may occur if these drugs are 
taken with metronidazole 
 
6.5 Prophylactic Medications and Procedures 
 
N/A 
 
6.6 Rescue Medications 
 
N/A 
 
 
 
7. STUDY PROCEDURES/EVALUATIONS 
 
 
7.1 Clinical Evaluations 
Baseline clinical evaluation will be provided during regularly scheduled clinical exam prior to 
enrollment including screening for TV. 
At enrollment, women will be asked to provide self-collected vaginal swabs for InPouch culture, 
NAAT, Gram stain testing for bacterial vaginosis (BV) and storage for future microbiota studies 
(FMS). The same procedure will be done at 4 week and 8 week follow up visits, however, at 4 
weeks the sites will have the option to obtain an additional vaginal swab for wet prep testing for 
TV.  
At each visit, medical records will be abstracted (when those records are available) for clinical 
data which may include signs/symptoms and co-infections. 
If a participant is positive by InPouch culture at her Test of Cure visit, and she has a viable 
organism, it will be tested for metronidazole sensitivity.  
 
 
 
 
 


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7.2 Laboratory Evaluations 
 
 
7.2.1 Clinical and Research Laboratory Evaluations and Specimen 
Collection 
Vaginal secretions will be used for Gram stain, InPouch testing, NAAT, TV genotyping, 
metronidazole resistance testing, wet prep, and FMS for participants who consented for FMS.  
 
There will be eight laboratory activities: 1) InPouch Culture readings, 2) InPouch culture 
processing for TV+ specimens, 3) Gram stain readings, 4) MTZ susceptibility testing, 5) storage 
of FMS swabs, 6) NAAT testing, 7) wet prep readings (where applicable) and 8) prepping of 
genotyping specimens.  All laboratory activities and staff expertise and procedures will be 
reviewed as required by the participating laboratories (i.e., LSUHSC, UAB, UMMC, CDC and 
NYU).   
 
Biohazard Containment: Laboratory personnel will follow their institutional requirements for 
biosafety procedures training. Universal Precautions for blood and body fluids will be followed.  
Study personnel will routinely use appropriate barrier precautions to prevent skin and mucous 
membrane exposure when contact with specimens. 1. Gloves will be worn handling specimens 
and handling items or surfaces soiled with body fluids. Gloves will be changed after contact with 
each patient. 2. Hands and other skin surfaces should be washed immediately and thoroughly if 
contaminated with body fluids. Hands will be washed immediately after gloves are removed. 3. 
Any items used for the collection or storage of biological specimens will be disposed of using 
the clinics’ biohazard containment and disposal systems.  
 
 
7.2.2 Specimen Preparation, Handling and Shipping 
 
All specimens will be labeled with the study id number and date of collection. 
 
InPouch cultures will be read at the clinic’s corresponding laboratory. Any positive baseline 
cultures will be processed and frozen for further testing. Frozen specimens will be stored at 
the site laboratories until shipment is required. Positive test of cure specimens may also be 
shipped live to the CDC for sensitivity testing. 
 
Wet prep at TOC will be an option for clinical sites that are able to perform wet preps for TV. 
Wet prep reads will be performed by study staff in order to have a point of care for repeat TV 
infections. 
 
FMS swabs will be frozen and stored at the clinic’s corresponding laboratory until shipment is 
requested. FMS shipments to the LSUHSC lab will occur annually.  Notation of consent to 
use this swab for future use is found in REDCap. 
 


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NAAT specimens will be collected at the sites and shipped to the LSUHSC or UAB 
laboratory for processing at least once per month 
 
Handling and shipping - A shipment manifest will be emailed prior to and included with all 
shipments. This manifest will be checked by the receiving laboratory staff for completeness 
of shipment. If any discrepancies arise, the receiving laboratory will contact the shipping 
laboratory for clarification. Any aberrations in shipment will be reported to the PI.  
 
There will be six types of specimen shipments.  
1) Transport to local labs- All specimens collected from the clinical sites (except TOC wet 
preps which will be read at the clinical site) will be couriered to their corresponding 
laboratories for processing. The specimens will be contained in biohazard packaging and 
carried in a climate controlled container to the labs.  
2) Live specimens for metronidazole resistance testing at TOC will shipped to Dr. Evan Secor, 
of the CDC’s parasitology laboratory, from all laboratory sites. These specimens contain only 
study ID and no other personal identifiers.  Dr. Secor will perform susceptibility testing on the 
specimens of women who have a repeat infection at test of cure follow-up. Positive live 
cultures will be kept incubated until ready for shipment, and then shipped to the CDC 
laboratory via overnight shipping. If necessary, the pouch may be inoculated with fresh culture 
medium if it cannot be immediately shipped (weekends or holidays) or if the parasites are at 
risk of dying because of length of time in the incubator before positive read. Shipment of 
InPouch will follow all standard regulations for shipment of Category B biological substances. 
InPouch will be securely closed after all fluid is pushed down into the lower chamber. The 
InPouch will be labeled with date of collection and study identification number. The InPouch 
will be wrapped in an absorbent material and placed into a sealable leak proof bag. The bag 
will be placed inside of a rigid container and sealed. A UN3373 label will be placed on the 
container before being placed into the Clinical Pak.  
3) Frozen specimens (processed cultures) will be shipped from the three laboratories to NYU 
laboratory for genotyping. If a live specimen shipment to the CDC (#2) is not a viable option, 
a frozen TOC specimen may also be shipped to CDC.  Frozen specimens will be shipped 
according to established laboratory protocols for Category B shipment of frozen specimens 
using dry ice. The boxes will be shipped overnight. Cryoboxes with frozen specimens will be 
surrounded with absorbent material and placed in a sealed plastic bag. This bag will be 
placed in an insulated shipment box with dry ice.  
4) Gram stain specimens from UMMC and UAB laboratories will be batch shipped to 
LSUHSC for reading; specimens collected at the New Orleans clinical sites will be delivered 
to the LSUHSC lab by courier at least weekly.  
5) FMS frozen specimens will be batched shipped from the UMMC and UAB laboratories to 
LSUHSC laboratory annually. These specimens will be stored for future microbiota studies; 
specimens collected at the New Orleans clinical sites will be delivered to the LSUHSC lab by 
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6) NAAT specimens  will be batch shipped to the LSUHSC or UAB for testing. Specimens 
should be labeled directly on the manufacturer label with a fine point Sharpie marker and 
each tube placed in individual Ziploc bags prior to being placed in a larger biohazard bag for 
shipment. 
 
 
  
7.2.2.1 Instructions for Specimen Storage 
 
InPouch cultures will be stored in an incubator (37oC) at the clinical and laboratory sites until 
final result is recorded. Positive baseline specimens will processed and stored frozen  
(-70 oC or colder) at each laboratory site until shipment to NYU. Gram stain slides are stored at 
room temperature at the laboratory sites until shipment to LSUHSC lab for reading .Gram stains 
will be read at LSUHSC. TV specimens for future microbiota studies (FMS) will be stored frozen 
(-70 oC or colder) at each laboratory site until annual shipment to LSUHSC where they will be 
stored frozen (-70 oC or colder) until future microbiota research resumes. Participants will have 
the ability to opt out of their FMS specimen storage/usage during the consent procedures. There 
will be a paragraph in the consent that outlines storage and use of frozen specimens, 
participants may choose to not have their specimens stored for long term use and still be able to 
participate in the study. If the participant opts out of future use of specimens, this will be 
indicated in REDCap and laboratories will be alerted to that status. At the end of the study, 
specimens of women who did not consent for specimen storage will be disposed of.   
 
 
  
7.2.2.2 Specimen Shipment Preparation, Handling and Storage 
InPouch Culture – InPouch cultures will be collected at the clinic sites and processed at the 
clinics’ corresponding laboratories. Once collected, the culture will be placed in an incubator at 
the clinics with a regulated temperature of 37°C. 
 InPouch specimens are couriered to the corresponding laboratories where trained technicians 
will be required to obtain at least 3 readings separated by at least 24 hours within a 7 day period 
or until a positive TV pouch result. A diagnosis of TV will be made after the first positive pouch 
reading. If all InPouch readings within the 7 day period are negative, the woman will be 
considered TV negative. The pouches will be labeled with the study identification number and 
date of collection. Results from all reads will be kept in a laboratory log at each site. 
 
Gram stain - Once the Gram stain slides are received at the LSUHSC they will be examined 
under low power magnification to find areas that have a concentrated amount of material to yield 
accurate readings. Then under oil immersion, 5 noncontiguous fields are examined that are 
representative of the material seen on the slide. These data are entered into the laboratory data 
form for each field. Results are entered into REDCap which calculates the Nugent score. Gram 
stain results will not be used for the clinical diagnosis of BV; they will only be used for research 
purposes. 
 
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perform susceptibility testing on the viable specimens of women who have a repeat infection at 
follow-up. Upon arrival at the CDC, parasites will be prepared according to CDC protocol100. In 
brief, they will be cultured in modified Diamond’s TYM medium at 37°C and transferred every 2 
days until an axenic culture is obtained. Duplicate assays for drug resistance will be performed 
and isolates will be cryogenically preserved in Diamond’s TYM medium supplemented with 5% 
dimethyl sulfoxide (DMSO) and agar. Metronidazole susceptibility will be assessed separately 
for each isolate in this study, after log growth is achieved. In brief, a stock solution (32 mg/ml) of 
metronidazole will be prepared in DMSO. Trichomonads (104) will be added to two-fold serial 
dilutions (400-0.2 μg/ml) of metronidazole in 96-well plates. After incubation, the plates will be 
examined using an inverted microscope to determine the MLC, the lowest drug concentration at 
which no motile trichomonad was observed. Metronidazole susceptibility is defined by a MLC 
from 0.2 to 25 μg/ml. Low to moderate metronidazole resistance was defined by a MLC from 50 
to 100 μg/ml. High metronidazole resistance was defined by a MLC 200 μg/ml or greater. The 
prevalence of in-vitro drug resistance will be compared by treatment study arm using chi-square 
test to determine if there is any indication drug resistance could account for some of the 
treatment failure. If the rates are similar by arm, we will ignore this potential confounder. 
 
 Prepping of InPouch specimens for TV genotyping- All positive InPouch cultures will be allowed 
to grow to a minimum of 50 parasites/field for up to 7 days.   Then, 3 ml of the InPouch culture 
will be removed from the pouch and spun down.  The pellet will then be resuspended in 2ml of 
10% DMSO in fresh Diamond’s media supplemented with 10% Horse serum.  The suspension 
will then be split between two internally-laced cryotubes and stored at -70oC or colder until 
shipped.  The stabilates will be sent to NYU on dry ice overnight and shipments will follow all 
standard regulations for shipment of Category B biological substances. Each clinical site 
laboratory will perform the specimen prep and batch freeze. Frozen specimens will be shipped 
to NYU according to a schedule determined by the PI.   
 
TV Genotyping methods - Until recently, genotyping of T. vaginalis was limited by the crudeness 
of the genotyping techniques, e.g. RAPDs and RFLPs101-105. These methods are highly sensitive 
to contaminating DNA or to slight variations in assay conditions, which influence their ability to 
accurately characterize T. vaginalis isolates.  A recently developed panel of 21 T. vaginalis-
specific microsatellites106 now provides a sensitive, reproducible, highly discerning set of genetic 
markers to accurately determine isolate-specific haplotypes and mixed genotype infections.  
Because of the high polymorphism of these markers and the number of loci that can be 
assayed, minor variations in haplotypes can be detected, allowing for high-resolution 
discrimination between related strains Dr. Carlton’s laboratory at NYU will genotype baseline 
and repeat infection specimens from all patients testing positive for TV at follow-up (~40 per 
year, ~120 total over 3 yrs).  Frozen stabilates will be sent to NYU overnight and shipments will 
follow all standard regulations for shipment of Category B biological substances. Both isolates 
from each individual will be genotyped at 11 MS loci as described106 with minor modifications. 
Briefly, microsatellite-specific NAAT reactions will be performed for each locus using 
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by capillary electrophoresis on an ABI 3130xl sequencer and scored using GeneMapper 4.0.  
The haplotypes determined for the baseline and repeat infection will be compared to make 
inferences about the origin of reinfection.  In addition, ~120 non-repeat infections (~40 each 
year) will also be genotyped to identify local population genetic characteristics and address the 
issue of confounding population structure. 
 
NAAT swabs will be placed in a GenProbe vaginal collection tube and stored at 2-30°C.  Swabs 
will be couriered daily from the clinic to the clinical laboratories and shipped at least monthly to 
the LSUHSC or UAB laboratory. Shipment will follow all Category B shipping restrictions.  Upon 
arrival, DNA isolation will be performed using published methods and nucleic acid diagnostic 
results will be returned within one week.  
 
Future microbiome study (FMS) swab – The vaginal swab will be placed in a tube containing 
100ul of nucleic acid preservative. The tube will be maintained at room temperature following the 
manufacturer’s recommendations until transport to the laboratory where it will be frozen at -70˚C 
or colder until processing for the extraction of DNA 
 
 
7.3 Substudies 
 
There are presently no sub-studies but the FMS may be added, pending provision of funding.   
 
 
8 STUDY SCHEDULE 
 
 
8.1 Screening  
 
Per standard clinic protocol at each site, a patient’s clinical examination will include testing for 
TV.  Pregnancy testing by the clinic will follow their standard clinical care guidelines. If the 
patient self-reports that she is HIV negative, is not pregnant as determined by clinical 
protocol, not treated for BV and TV positive by wet prep, she will be referred by her clinician 
to the study personnel for potential enrollment. At sites where NAAT screening is performed, 
women may be referred because of a NAAT TV+ result. Study staff will discuss the study with 
the patient, review eligibility criteria and obtain informed consent.  
 
 
8.2 Enrollment/Baseline  
 
The study will be described to potential participants by study staff and any questions will be 
answered and documented in the study records. Each site has an eligibility checklist for the 
study staff to use to confirm eligibility.  As part of her eligibility checklist, staff will determine if 
a potential participant was given a pregnancy test at her clinical visit and confirm that the test 
was negative or that she had a hysterectomy or is post-menopausal for at least two years. If 
the woman is willing to participate and is eligible for the study, staff will obtain informed 


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consent and provide a copy to participant. After consent is obtained, if a woman did not 
provide a urine pregnancy test as part of her clinical visit or meet the other criteria to 
determine she was not pregnant, she will be asked to provide a urine sample for testing. If the 
test is positive, women will be told that she is ineligible to continue with the study protocol 
since pregnancy is an ineligibility criterion. Study staff will provide her with her baseline 
compensation and refer her for pregnancy counseling as per each clinic’s standard of care. 
The participant will be withdrawn prior to randomization and her randomization number will be 
used for the next participant. A participant may also be withdrawn from the study prior to 
randomization if she is found to meet other ineligibility criteria post-consent and pre-
randomization. In these cases, she would receive her compensation and her randomization 
number would be used for the next participant. 
 
If the participant is negative for pregnancy, she will undergo the audio computer assisted self-
interview (ACASI). This survey will take approximately 30-45 minutes to complete and will be 
conducted after the clinical  exam and written informed consent is obtained  but before 
randomization to treatment. Information elicited will include detailed information about 
participants’ demographics, socioeconomics, STI risk behavior and symptoms, substance 
use, and birth control methods, as well as partner specific information about sexual behavior, 
condom usage, and partnership status.  
 
Women will be asked to self-collect vaginal swabs for Gram stain testing, In Pouch, TV NAAT 
and FMS. The participant will be given three or four sterile swabs and tubes and instructed on 
how to self-swab, place the swab in the tubes and return to the study office.  
 
Study staff will process the specimens: for Gram stain, the swab will be carefully rolled by 
study staff over a predefined area of a glass slide, air dried, and stored in a slide cover; for 
FMS, the swab will be placed in a tube with preservative; for InPouch, the swab will be placed in 
the culture medium; for NAAT, the swab will be placed in the GenProbe tube. The specimens will 
be labeled with study identification numbers and dates of collection.  
 
She will then be randomized to treatment arm (Single dose or 7 day dose). A blocked 
randomization scheme will be used to avoid “runs” in the randomization process. Pre-
numbered, sealed envelopes will be selected sequentially and opened for each participant 
who will then be enrolled in the indicated arm. 
 
If a woman is randomized into the single oral dose MTZ arm, she will be given the 2 g dose of 
MTZ and asked to ingest it under direct observation. If a woman is randomized into the 7 day 
oral dose MTZ arm, she will be given the 500 mg BID for 7 days and asked to ingest the first 
dose under direct observation. 
 
 
 


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All participants will receive the same counseling: to refrain from unprotected sexual 
intercourse until 1 week after they and their partner(s) complete the medication, to refrain 
from alcohol consumption while taking the medication and for 24 hours after completion; 
MTZ-related adverse events will be discussed including rash, dizziness, headache, diarrhea, 
nausea, vomiting, fatigue, upset stomach, dark red-brown urine, and change in taste 
sensation (metallic taste) or dry mouth. It will also be explained that MTZ can cause urine to 
darken in color but that this effect is not harmful. Participants in the 7-day arm will be given 
additional counseling on the importance of taking all doses of the medication. 
 
If a participant’s clinical TV positive test result is not confirmed TV-positive by InPouch culture 
or NAAT, she will be withdrawn from the study. These testing procedures and de-enrollment 
potential will be fully explained in the consent form. Women will receive $20 compensation 
after completion of the baseline enrollment visit. Women will receive a study contact card that 
has all contact information for study personnel so that she may contact staff in case of 
appointment change, questions, or adverse events. She will be instructed to keep this card 
during the course of the study period. If she is withdrawn, she will keep her baseline 
compensation but told she will not need to attend her follow-up visits. 
 
 
 
8.3 Follow-up  
 
Participants will be scheduled for a Test of Cure (TOC) follow up visit 4 weeks after treatment 
completion with a window of 3-12 weeks post-baseline for the 2 gm MTZ dose and 4-13 
weeks post-baseline for the 7 day MTZ dose. Prior to the follow-up visit, women will be 
contacted by study staff via their preferred method (i.e., cell phone, text message, or email) to 
remind them of their study visit. If they miss their scheduled visit, study staff will attempt 
contact at least five times. All contact attempts will be noted in the participant’s file.  
 
At follow-up visits, she will undergo the ACASI survey, and testing for TV and BV. For 
specimen collection, women will be reminded of vaginal self-swab procedures and asked to 
collect up to five vaginal swabs, place them in the sterile tubes and return to study office. 
Study staff will place one swab in the InPouch, one in the FMS tube, one for NAAT and use 
the other swab to prepare a Gram stain slide as described above. For sites that will perform a 
wet prep at TOC, a swab will be prepared for wet prep and read by the study staff. Specimens will 
be labeled with study identification number and date of collection. Procedures for processing 
these specimens and reporting of results will be same as described for baseline procedures. 
Any positive InPouch or wet prep will be reported to the participant’s provider at the clinic to 
arrange for treatment. The study does not provide medication for participants after baseline 
enrollment and initial treatment. In the case of a TV positive result at follow up, clinical staff 
with provide treatment in accordance with clinic protocols.  Gram stain results are for study 
evaluation only and will not be used as a diagnostic tool for providers.  After completion of 
visit, participant will receive $50 compensation; contact information and preferred methods of 


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contact will be updated.   
 
If a woman is TV positive by InPouch culture at her TOC visit, she will have concluded her 
follow up visits. If, however, a woman is TV negative by InPouch but TV positive by NAAT 
testing, she may be asked to return for a follow-up visit 4 weeks post TOC visit (3-8 weeks 
after her TOC visit) for further evaluation. At the follow-up visit 4 weeks post TOC, she will be 
asked to self-collect up to five vaginal swabs and complete an ACASI survey as in her TOC 
visit. She will be given $50 compensation and contact information and preferred methods of 
contact will be updated.  If she tests TV positive by InPouch at this visit, results will be 
provided to clinical staff in order for her to receive treatment as standard clinical protocol.  
 
 
8.4 Final Study Visit 
The final study visit will either be the TOC visit at 4 weeks post treatment completion or a 
follow-up visit 4 weeks post TOC visit (if she was NAAT+/InPouch- at her TOC visit and asked 
to return).  
 
 
8.5 Early Termination Visit 
 
After providing informed consent and undergoing randomization, it is possible that a woman 
will refuse the intervention. If this happens, she will still receive her baseline compensation for 
dedicating time to the study up to that point (the randomization is near the end of the baseline 
visit). She will be referred back to her clinician for treatment of TV as per clinical protocol. Her 
self-collected vaginal swabs will be discarded. 
 
 
8.6 Pregnancy Visit 
 
Women will not be enrolled if they are pregnant. If they become pregnant during the course of 
the study, it will not affect study enrollment because they would have already been treated for 
TV. If it is determined that the participant was pregnant at the time of treatment, the woman and 
her child will be followed according to the site specific regulatory requirements.   
 
 
8.7 Unscheduled Visits 
 
Since the study is housed within the clinics, there may be times when a participant has a clinic 
visit and is not scheduled for a study visit. If this occurs and the participant inquiries about 
completing their study visit during their clinic time, study staff will review the participants file to 
see if she is within her follow up window, if so, she can complete her follow up visit, if not, she 
will have to return at her scheduled date/time. 
 
If a participant has persistent symptoms or other complaints and comes to the clinic for an 
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and treatment. She will keep her regularly scheduled TOC visit and her interim clinic visit will be 
noted. 
 
The following is a schedule of visits and subject compensation at each visit 
Study Visit Schedule 
Visit Number 
 
When is it? 
Acceptable window 
of time to complete 
Compensation 
 
Visit 1 
 
 
Date subject enrolls 
in study 
 
N/A 
 
$20 
 
 
Visit 2 
 
 
 
4-weeks after  
scheduled completion 
of the medicine 
If 1-day dose: 
3 weeks-12 weeks 
after visit 1 
 
$50 
If 7-day dose:  
4 weeks-13 weeks  
after visit 1 
 
$50 
 
Visit 3 
*only if applicable 
 
4-weeks after visit 2 
 
3 weeks-8 weeks after  
visit 2 
 
$50 
*You may be scheduled for this visit only if the NAAT is positive and the culture is negative. 
 
 
9. ASSESSMENT OF SAFETY 
 
 
9.1 Specification of Safety Parameters 
 
Metronidazole in the 2gm dose is an FDA approved treatment for TV. The 7 day 500mg BID 
dose is recommended in the CDC treatment guidelines for TV, however, is not currently FDA 
approved.   
 
There are three main safety concerns: 
 
1) Adverse drug reactions including, allergy, hypersensitivity reaction, or other adverse 
reaction to metronidazole, alcohol use within 24 hours of taking medication, and 
contra-indications with other medications.  
2)  Pregnancy in a woman who tested negative at entry. 
3) That discussing their infection with partners may put participants at risk for verbal or 
physical abuse by disclosing their STI to their partners. 
 
 
 
 
 
 


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9.2 Definition of an Adverse Event (AE) 
 
Vomiting within 2 hours of consumption of the medication with no other signs of allergic reaction 
to MTZ will not be considered an adverse event but will be documented. Adverse events include 
eye pain, sudden vision changes, sore throat, persistent fever, unusual bleeding/bruising, 
severe stomach pain, persistent nausea/vomiting, fatigue, hypersensitivity reaction or other 
adverse reaction to MTZ. 
 
Any form of intimidation, verbal or physical abuse will be considered an adverse event. 
 
 
9.3 Definition of a Serious Adverse Event (SAE) 
 
An adverse event is considered “serious” if in the view of the Investigator, it results in any of the 
following outcomes: death, a life threatening adverse event, inpatient hospitalization or 
prolongation of existing hospitalization, a persistent or significant incapacity or substantial 
disruption of the ability to conduct normal life functions, or a congenital anomaly/birth defect. 
Important medical events that may not result in death, be life-threatening, or require 
hospitalization may be considered serious when, based upon appropriate medical judgment, 
they may jeopardize the patient or subject and may require medical or surgical intervention to 
prevent one of the outcomes listed in this definition. Serious adverse events include seizures, 
encephalopathy, aseptic meningitis, optic and peripheral neuropathy, leukopenia, and a 
hypersensitivity reaction including Stevens-Johnson syndrome and toxic epidermal necrolysis.   
 
 
9.4 Methods and Timing for Assessing, Recording, and 
Analyzing, Managing Safety Parameters 
  
MTZ has been used for the treatment of TV for over 40 years.  However, we will monitor 
adverse reactions in an ongoing basis and by the DSMB every 6 months.  
 
The most serious adverse reactions reported in patients treated with MTZ have been convulsive 
seizures, encephalopathy, aseptic meningitis, optic and peripheral neuropathy, the latter 
characterized mainly by numbness or paresthesia of an extremity. Since persistent peripheral 
neuropathy has been reported in some patients receiving prolonged administration of MTZ, 
patients should be specifically warned about these reactions and should be told to stop the drug 
and report immediately to their physicians if any neurologic symptoms occur. The most common 
adverse reactions reported have been referable to the gastrointestinal tract, particularly nausea 
reported by about 12% of patients, sometimes accompanied by headache, anorexia, and 
occasionally vomiting; diarrhea; epigastric distress; and abdominal cramping. Constipation has 
also been reported. The following reactions have also been reported during treatment with MTZ: 
Mouth: A sharp, unpleasant metallic taste is not unusual. Furry tongue, glossitis, and stomatitis 
have occurred; these may be associated with a sudden overgrowth of Candida which may occur 
during therapy. Hematopoietic: Reversible neutropenia (leukopenia); rarely, reversible 


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thrombocytopenia. Cardiovascular: Flattening of the T-wave may be seen in 
electrocardiographic tracings. Central Nervous System: Encephalopathy, aseptic meningitis, 
convulsive seizures, optic neuropathy, peripheral neuropathy, dizziness, vertigo, incoordination, 
ataxia, confusion, dysarthria, irritability, depression, weakness, and insomnia. Hypersensitivity: 
Urticaria, erythematous rash, Stevens-Johnson Syndrome, toxic epidermal necrolysis, flushing, 
nasal congestion, dryness of the mouth (or vagina or vulva), and fever. Renal: Dysuria, cystitis, 
polyuria, incontinence, and a sense of pelvic pressure. Instances of darkened urine have been 
reported by approximately one patient in 100,000. Although the pigment which is probably 
responsible for this phenomenon has not been positively identified, it is almost certainly a 
metabolite of metronidazole and seems to have no clinical significance. 
Other: Proliferation of Candida in the vagina, dyspareunia, decrease of libido, proctitis, and 
fleeting joint pains sometimes resembling “serum sickness.” If patients receiving MTZ drink 
alcoholic beverages, they may experience abdominal distress, nausea, vomiting, flushing, or 
headache. A modification of the taste of alcoholic beverages has also been reported. Rare 
cases of pancreatitis, which generally abated on withdrawal of the drug, have been reported. 
Crohn’s disease patients are known to have an increased incidence of gastrointestinal and 
certain extra-intestinal cancers. There have been some reports in the medical literature of 
breast and colon cancer in Crohn’s disease patients who have been treated with metronidazole 
at high doses for extended periods of time. A cause and effect relationship has not been 
established. Crohn’s disease is not an approved indication for MTZ. 
 
See Section 10 for a greater description of the monitoring process and  
http://www.rxlist.com/flagyl-drug.htm  (medication insert) for more details on side effects. 
 
 
9.4.1 Methods and Timing for Assessment 
Adverse events reported by participants will be recorded and reported to the institutional IRBs 
according to their reporting requirements. At each follow up visit, staff will inquire if any 
metronidazole was taken since last visit and if there were any adverse events from taking the 
medication. This information will be recorded in study data.  
 
 
9.4.1.1 
AE/SAE Grading and Relationship Assignment  
Serious adverse events to metronidazole by participants will be recorded by severity and 
relation to dosing at each clinical site. These will be immediately reported to the Lead PI, 
other Investigators, and institutional IRBs according to their reporting requirements. DSMB 
will be notified.  
 
 
 
9.4.2 Recording/Documentation 
A standard event reporting form will be used by all sites. In the event of an adverse event, it 
will be mandated that this form must be filled out by study personnel within 24 hours of the 


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reporting of the event and sent to the investigators for review. A complete description of the 
adverse event will include time of onset, length of event, relation to metronidazole, and 
resolution and severity of event. 
 
 
9.4.3 Analysis/Management 
 
Adverse events will be considered in the analysis of the endpoint in cases where they affect 
adherence to the drug.  
 
 
9.5 
Reporting Procedures 
The Lead PI and the site PI(s) will discuss the reported event and decide if it meets the 
standard for institutional IRB reporting of adverse events. If so, they will report the event 
according to their IRB reporting requirements. The DSMB will also be notified of the AE or 
SAE by the Lead PI. The site investigators will be notified to discuss the event and resolution 
with the patient to make certain the participant is treated appropriately.  
 
 
9.5.1 Specific Serious Adverse Event Requirements 
 
All serious adverse events will be recorded on the case report form as SAE. Investigators at the 
clinical site who are the study physicians will work with the Principal Investigator to resolve the 
SAE. The study physical will follow up with participants and report resolution success to the PI. 
Any AE that meets the division’s or protocol-specific expedited (or serious) adverse event 
reporting criteria must be submitted to the NIAID’s pharmacovigilance contractor, at the 
following address, using the appropriate form (if applicable): 
 
DMID  
 Clinical Research Operations and Management Support (CROMS)6500 Rock Spring Dr, Suite 
650 
Bethesda, MD 20814, USA 
SAE Hot Line: 1-800-537-9979 
SAE FAX: 1-800-275-7619 
SAE Email Address: PVG@dmidcroms.com 
The study clinician will complete an Expedited or Serious Adverse Event Form within the 
following time guidelines: 
All deaths and immediately life threatening events, whether related or unrelated, will be 
recorded on the Expedited or Serious Adverse Event Form and faxed/electronically 
communicated within 24 hours of site awareness.  
Adverse events other than death and immediately life threatening events, that meet expedited 
reporting criteria, regardless of relationship, will be faxed/electronically communicated by the 
site within 72 hours of becoming aware of the event.   


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Other supporting documentation of the event may be requested by the pharmacovigilance 
contractor and should be provided as soon as possible. 
All reportable AEs will be followed until satisfactory resolution or until the Principal Investigator 
or Sub-investigator deems the event to be chronic or the participant to be stable.  
REGULATORY REPORTING FOR STUDIES CONDUCTED UNDER NIAID-SPONSORED IND 
Following notification from the investigator, the IND sponsor/Lead PI, will report events that are 
both serious and unexpected and that are associated with Study Agent(s)/Intervention(s) to the 
FDA and other applicable health authorities within the required timelines as specified in 21 CFR 
312.32: fatal and life threatening events within 7 calendar days (by phone /fax/electronic 
communication) and all other serious adverse events in writing within 15 calendar days.  All 
serious events designated as “not associated” to Study Agent(s)/Intervention(s), will be reported 
to the FDA at least annually in a summary format. 
 
 
9.6 
Reporting of Pregnancy 
 
Interventions are given at baseline visit only. All participants found to be TV positive at a follow 
up visit, will be referred to clinic providers to be retreated at the provider’s discretion. The study 
does not treat participants or their partners with medication at follow up visits. Women who 
become pregnant during the study remain eligible for study participation. Pregnancy will not be 
recorded as an adverse event but will be noted in study charts and the pregnant participant and 
their child may be followed according to the site IRB regulations. 
 
 
9.7 
Type and Duration of the Follow-up of Participants after 
Adverse Events 
Because this is a phase III study of medications that are being used for their intended purpose, 
we anticipate that serious adverse events will be a rare occurrence.  Participants who 
experience unresolved nausea and/or vomiting or allergic reaction will be referred to the clinic 
providers and they will provide care according to clinic protocol.   
 
 
9.8 
Modification of Study Agent(s)/Intervention(s) for a 
Participant 
 
Metronidazole in both treatment doses is the CDC recommended treatment for TV. The study 
will treat participants at baseline only. There will be no need for modification of study agents 
unless the participant is unable to complete a dose. Clinical protocols will be followed in case 
of severe reaction to MTZ. 
 
 
 
 
 


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9.8.1 
Dose / Schedule Modifications for a Participant 
 
If the participant is unable to complete the dose of MTZ, she will be referred to her clinical 
provider for alternative treatment.  
 
 
9.9 
Halting Rules for the Protocol 
 
Since the study is taking place at public clinics, the investigators are physicians at the clinics, 
the drug intervention is recommended as treatment by the CDC, and the investigators have 
extensive experience, it is expected that SAEs will be minimal. If, however, during the course of 
the study, the number of side effects exceeds what is considered normal, the DSMB will 
recommend whether to continue without modification, continue with specified modification, 
discontinue one or more arms of the study, discontinue enrollment at one or more clinical sites 
or halt or modify the study until more information is available.  If a major change is 
recommended, the DSMB will report this directly to the NIH Program Officer who will contact the 
PI and collectively make a determination on how to proceed.  All DSMB recommendations and 
proposed changes to the protocol will be reported to the IRB.  All adverse events will be 
reported to medical provider responsible for the participant and followed clinically to assure that 
the participant experiences the minimal amount of sequelae possible. Unexpected adverse 
events are reported to the participating institutions per their respective protocols.  
 
 
9.10 Stopping Rules for an Individual Participant/Cohort 
Criteria for Discontinuation of Study Agent(s)/Intervention(s): 
-if they are randomized to an arm and are unable to tolerate the dose the study agent will be 
discontinued.  
Criteria for Withdrawal of a Participant: 
-if they become incarcerated and are unable to attend follow up visits 
-if any clinical adverse event, laboratory abnormality, concurrent illness, other medical condition 
or situation occurs such that continued participation in the study would not be in the best interest 
of the participant. 
-if a woman is found to be pregnant after consent but prior to randomization 
-if a woman is found to be ineligible after consent but prior to randomization 
-if a participant initial TV positive wet prep result is not confirmed by either InPouch culture or 
TV NAAT test from her enrollment visit 
 


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9.11 Premature Withdrawal of a Participant 
Voluntary withdrawal is always an option for participants without affecting their clinical care. 
Women may choose to withdraw from the study at any time. If they choose to withdraw the data 
that has been previously collected will be included in the analyses. 
 
 
9.12 Replacement of a Participant Who Discontinues Study 
Treatment 
There is no plan in the protocol to replace women who discontinue the study. Enrollment will 
continue up until 2 months prior to the study end date. 
 
10. 
Clinical Monitoring Structure 
 
 
10.1 Site Monitoring Plan 
The Principal Investigator and Tulane study staff under the direction and supervision of the PI, 
will conduct regular site monitoring to ensure human subject protection and that study 
procedures are being conducted as per protocol and Manual of Procedures as outlined in 
section 12.0. For the first 4 months of enrollment, weekly conference calls will be held with 
investigators and study personnel at sites to ensure start up activities are following protocol, any 
questions can be answered, and clinic flow and specific clinical issues can be addressed. The 
PI and Program Manager are available at any time via email or cell phone to address any urgent 
issues. Quarterly site visits will be conducted by the PI, or her designee. At these visits, at least 
10% of study charts will be pulled and reviewed, all consent forms will be reviewed and consent 
procedures will be discussed. There will also be a systematic review of enrollment statistics (i.e., 
number of eligible patients, refusal log, ineligibility log). Weekly data transfer to the research 
office at Tulane University will allow the program manager to review data collected for any 
errors or discrepancies and report back to sites to resolve any inconsistencies.  
 
Women will be systematically asked if they experienced any of the common side effects on the 
TOC CRF. 
 
 
10.2 Safety Monitoring Plan 
 
The safety of the subjects is paramount. AE reports are monitored on an ongoing basis by the 
Principal Investigator at monthly meetings and by the DSMB.  All SAEs are reviewed by the site 
and Lead PI (or designee) within 2 working days of receipt.  Both AEs and SAEs are reported to 
the IRB according to each institution’s regulations including the Tulane IRB.  The DSMB reviews 
these at their bi-annual meetings. Events will be reported to the FDA in accordance with 
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10.2.1 Safety Review Plan by the DSMB / SMC 
 
The DSMB will be responsible for monitoring all aspects of the study, including those that 
require access to blinded data, and will follow the procedures detailed in the DSMB charter (see 
appendix). A brief description of the DSMB activities is as follows.  
 
The “convening authority” for the DSMB is NIH-NIAID.  The DSMB will consist of three experts 
who are not otherwise affiliated with the study. The DSMB will meet semiannually and may meet 
more frequently if requested by members of the DSMB.  These meetings will consist of three 
sessions:  Open Session, Closed Session, and Closed Executive Session.  The Data 
Coordinating Center (DCC) representative will be responsible for preparing and presenting up-
to-date statistical reports on the progress of the study at these meetings.  These reports will 
include data on recruitment, randomization, adherence, adverse drug responses as well as 
statistical tests and special analyses requested by the DSMB.  The Open Sessions will be 
attended by DSMB members, a FDA representative, a DCC representative, the principal 
investigator and members of the study team as needed.  All voting will occur during the Closed 
Executive Session, which is only attended by DSMB members.  
 
During the active recruitment phase, the DSMB will monitor the progress of recruitment and the 
random allocation of participants to the various treatment arms and may recommend 
modifications in (or termination of) the trial if the study design goals are not being met.  The 
DSMB may recommend discontinuation of any of the treatment arms for safety reason or a very 
low probability of successfully addressing the study hypotheses within a feasible time frame, 
because of inadequate recruitment, compliance, drug response, effect size of outcome, etc. All 
votes will be decided by a simple majority. The NIAID will make the final decision on whether or 
not to accept the DSMB's recommendation to discontinue any component of the study. 
 
The approval of the DSMB will also be required for any significant changes in the protocol 
recommended during the course of the study. 
 
11. STATISTICAL CONSIDERATIONS 
 
 
11.1 Overview and Study Objectives 
 
The overall goal of this project is to determine the influence of index treatment and host factors  
on repeat TV infections among HIV-negative women in two specific objectives: 1) To determine 
if the multi-dose (alternate) MTZ is superior to single dose (recommended) for the treatment of 
TV among HIV-negative women. 2) To determine if altered vaginal flora (measured by Nugent’s 
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11.2 Study Population 
English speaking, HIV negative women, who are not pregnant or breastfeeding, and are of the 
age of majority, who attend a clinical exam at 4 public clinics and are found to be positive for 
Trichomonas vaginalis. 
 
 
 
11.3 Description of the Analyses 
The TV positive rate will be compared between the two arms for superiority. Additional analyses 
will be conducted to compare the rates stratified by BV status.  
 
 
11.4 Measures to Minimize Bias 
Enrollment/ Randomization/ Masking Procedures 
 
After eligibility is assessed, informed consent is obtained and the woman has completed the 
ACASI survey and self-swab collection, she will be randomized to treatment arm. A blocked 
randomization scheme will be used to avoid “runs” in the randomization process. Each site will 
have its own blocked randomization scheme. Pre-numbered, sealed envelopes will be selected 
sequentially and opened for each participant who will then be enrolled in the indicated treatment 
arm.  Because we are conducting a phase III trial and behaviors associated with the 
interventions are important, we will not attempt to make the single dose mimic a 7-day dose by 
supplementing with placebo. The trial will, therefore, be un-blinded. There will be no 
replacement of participants who discontinue early. Enrollment will continue through two months 
prior to study end. 
 
Study personnel will know which arm the participant was randomized to. This information will 
not be disclosed to laboratory personnel. The Program Manager will periodically ensure that all 
participants were randomized to the correct treatment arm as indicated in the randomization 
scheme.  Any discrepancies will be immediately discussed with investigators to prevent further 
error. 
 
 
 
11.5 Appropriate Methods and Timing for Analyzing Outcome 
Measures. 
The primary outcome measure is TV infection. All women will be TV positive at baseline and will 
be screened for TV using InPouch culture and NAAT at follow up visits. Binary (TV positive or 
TV negative) 
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BV which will be measured by self-collected vaginal swabs and Gram stain screening at all 
visits. Categorical (Scores of 7 -10 are considered to indicate BV). This measure will add 
information about the primary outcome measure by indicating whether BV affects TV repeat 
infections. 
Re-exposure, which will be self-report by the participant for each partner. This data will be 
collected on the behavioral survey at follow up visits. Binary (partner treated and /or no sexual 
exposure prior to screening vs. partner not treated and sexual exposure prior to screening, This 
measure will allow us to adjust for the confounding effects of sexual exposure/re-exposure. 
 
 
11.6 Study Hypotheses 
 
From the two aims, there are two hypotheses:  
H1: Multi-dose (alternate) MTZ is superior to the single dose (recommended) for the treatment 
of TV among HIV-negative women.  
H2: Altered vaginal flora (measured by Nugent’s score) interferes with the MTZ treatment of TV 
for the single dose but not the multi-dose.  
 
 
11.7 Sample Size 
 
 Considerations 
 
This RCT will allow for evaluation of index dosing of MTZ by BV status. This study examines 
two hypotheses simultaneously:  
     H1:  Women receiving multi-day MTZ will be less likely to test TV positive at TOC compared 
to women who receive the single dose MTZ. 
     H2:  This effect (H1) will only be observed among women who have BV (Nugent score > 7). 
 
From our pilot work, we found the rates of repeat infection at TOC to be 16.2% for single dose 
and 10.7% for multi dose at a power of 0.80, we will need 1206 subjects.  If we account for a 5% 
Inner Class Correlation (ICC) for correlation of the subjects within the 4 sites using the formula 
1=(M-1)*ICC.  We will need to inflate by 15%.  We will also inflate by 20% to accommodate for 
our anticipated follow-up for a required sample size of 1664. We will have 1332 evaluable unites 
at TOC, which will provide adequate power taking into consideration the ICC.  
 


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11.8 Maintenance of Trial Treatment Randomization Codes 
Randomization will occur at the end of each baseline study visit. Randomization codes will be 
determined by a block randomization strategy at each site. Sealed envelopes will contain a 
study identification number on the outside and the randomization arm on the inside. Study staff 
will chose randomization envelopes sequentially and only open the card after enrollment, survey 
and specimen collection has occurred. There will be a separate staff member who will create 
and number the envelopes thereby shielding clinic study staff from knowing the randomization 
scheme. No study staff at the clinic will have access to the randomization database or 
numbering scheme. Every six months, a randomization interim analysis will be performed by 
Tulane staff for DSMB review to ensure that the randomization strategy is successful. The 
randomization arm will be noted on the study file and in the participant’s data once the baseline 
visit is completed. No laboratory or clinical staff will have access to the randomization database. 
 
 
11.9 Participant Enrollment and Follow-Up 
Women will be enrolled from three public clinics in New Orleans, LA (CrescentCare Health and 
Wellness, Birmingham, AL (JCDH STD Specialty Clinic) and Jackson, MS (Crossroads Clinic). 
Each will continue to enroll up until two months from study end to allow sufficient time for follow 
up; therefore anticipated enrollment duration will be 30 months. The clinics’ census is adequate 
to achieve sample size.  
TV+ Women 
(N=2,702)
Figure 1.   
Randomization Scheme 
Eligible TV+ Women 
(N=2,080) 77%
In-eligible/un-locatable 
TV+ Women 
(N=622) 23%
Eligible/Accept Women 
(N=1664) 80%
Eligible/Refuse Women 
(N=416) 20%
Single-dose 
(N=832) 
Multi-dose
(N=832)
Single-dose complete FU
(N=666) 80% 
Multi-dose complete FU
(N=666) 80%
LTFU (N=166) 
LTFU (N=166) 


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11.10 Planned Interim Analyses 
The DSMB will be responsible for monitoring all aspects of the study, including those that 
require access to blinded data, and will follow the procedures detailed in the DSMB charter. The 
Data Coordinating Center (DCC) representative will be responsible for preparing and presenting 
up-to-date statistical reports on the progress of the study at semiannual meetings.  These 
reports will include data on recruitment, randomization, adherence, adverse drug responses, as 
well as statistical tests and special analyses requested by the DSMB. During the active 
recruitment phase, the DSMB will monitor the progress of recruitment and the random allocation 
of participants to the various treatment arms and may recommend modifications in (or 
termination of) the trial if the study design goals are not being met.  
 
 
11.11 Safety Review 
Investigators and the DSMB may recommend discontinuation of any of the treatment arms for 
safety reasons or a very low probability of successfully addressing the study hypotheses within 
a feasible time frame, because of inadequate recruitment, compliance, drug response, effect 
size of outcome, etc. This discontinuation may apply to one or all sites. All votes will be decided 
by a simple majority. The NIAID will make the final decision on whether or not to accept the 
DSMB's recommendation to discontinue any component of the study. 
 
 
11.12 Immunogenicity or Efficacy Review 
Since this is a Phase III trial of medications that are being used for their intended use, there 
should be no need to conduct interim analyses.   
 
 
11.13 Final Analysis Plan 
 
Analyses will be conducted in an intent-to-treat manner with variables categorized per protocol. 
To assure that randomization has been achieved, selected demographic, clinical and behavioral 
(including medication adherence and sexual re-exposure) factors will be compared by study 
arms using chi-square, t-test or ANOVA, where applicable. If randomization was found to be 
successful (as indicated by even distribution of potential confounders) then analyses will be 
conducted with no need to adjust for confounding.  If randomization was not achieved, then 
associations will be explored for potential confounding and if found these factors will also be 
included in the model. From the two aims, there are two hypotheses: 
 H1:  Women receiving multi-day MTZ will be less likely to test TV positive at TOC compared to 
women who receive the single dose MTZ. 
 H2:  This effect (H1) will only be observed among women who have BV (Nugent score > 7). 
  
Analysis: The research questions will be answered using a multivariable logistic regression 
analysis to examine the effect of single versus multi-dose (H1) and the differential impact of BV 
on this effect (H2).  This primary logistic model contains two main effects (i.e. treatment and BV) 


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and 1 first order interaction (BV by index treatment)).  The model (1) will be:  g(Yi )= β0 + β1 + 
β2+  +  β1 * β2    where:    g(Yi) = log odds of repeat infection, β0= coefficient for the intercept, β1 = 
(Factor 1) single versus multi-dose, β2 = (Factor 2) BV at time of visit 
     
All analyses will be conducted in SAS by Tulane staff under the direction of Drs. Kissinger and 
Myers. Because we will use strict protocols and employ tight supervision of the study sites and 
the study populations are similar (mostly African American and underserved) we do not 
anticipate site variations but we will examine for any differences and if found, we will include a 
site variable in the models.  We do not anticipate a three-way interaction, and our simulations 
(see below) support that belief.  We will, however, run a fully parameterized model including all 
main effects, first order interactions, and second order interaction before running the primary 
analysis model (1) above.  We will consider any p-value less than 0.05 to be significant and any 
p-value less than 0.10 as near-significant.  If there is unexpected significant or near-significant 
interaction, we will stratify on BV status and assess the impact of index treatment (single vs. 
multi-dose) and any possible interaction separately for BV positive and BV negative women.  
      
Additional analyses– The ACASI will allow for examination of index adherence to medication, 
index knowledge of partner treatment, sexual exposure and the nature of the sexual act and 
sexual partner, condom use.  These factors will be assessed by arm to determine if any 
confounding occurred and if so, these analyses will be adjusted for these factors or stratified by 
these factors.   
 
Outcome measures – The study 
is powered for repeat infections.  
Since we will have information on 
sexual exposure and genotyping, 
we can also refine this outcome 
measure to examine treatment 
failure (H1 & H2) and reinfection 
and will use the algorithm 
depicted in figure 4.  
 All analyses will be conducted in 
SAS by the Tulane staff under the 
direction of Drs. Kissinger and 
Myers. As the data collection 
instruments are designed to 
minimize missing data we do not anticipate an excessive amount.  However, imputation 
techniques will be utilized to compensate for missing data (e.g. multiple imputation and 
maximum likelihood).  Sensitivity analyses will be conducted to ensure that the method chosen 
to account for missing data does not bias the study’s results.  Additionally, the characteristics of 
those who complete the study will be compared to those who drop out to determine whether 
drop out is informative.  If not, multiple imputation methods will be used for initial analyses.  If, 
Figure 4: Algorithm for 
determining origin of repeat 
infection at TOC 


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instead, data are non-ignorably missing, weighted regression methods will be explored but 
extreme caution will be used in interpreting results.  Regardless of missingness mechanism, 
complete case analysis will also be performed for comparison.   
 
12. QUALITY CONTROL AND QUALITY ASSURANCE 
 
Dr. Kissinger will serve as the study PI and all co-investigators will be accountable to her. She 
will be overseen by the DSMB and the NIAID Project Officer.  There are three clinical sites:  the 
CrescentCare Health and Wellness in New Orleans, the JCDH STD Specialty Clinic in 
Birmingham, AL and Crossroads Clinic in Jackson. All provide STI services.  Drs. Lillis, Muzny, 
and Mena will serve as site PI’s, respectively.  The Program Manager will supervise the site 
Study Coordinators who will, screen, enroll, and follow all participants. Dr. Kissinger and Tulane 
study staff, under the direction and supervision of Dr. Kissinger, will conduct site visits at least 
once a quarter to assure that all study activities adhere to the study protocol.  In all site 
laboratories, a trained lab technician will read TV InPouches and prepare specimens for storage 
and shipment to the appropriate labs.  The study protocol, manual of operations, currently 
approved consent forms and other study related materials will be posted in a shared study 
Box.com project folder that is password protected. Site study staff/co-investigators will prepare 
monthly recruitment and follow-up statistics that will be presented at monthly conference calls. 
Lab PIs will supervise their technicians.   
     The REDCap system will be used for data entry of clinical visits, results and contacts. 
Contact data will be kept in a separate REDCap database and will be site specific, such that 
sites cannot see other sites’ contact databases.  Tulane study staff, under the direction and 
supervision of Dr. Kissinger, will have access to this information for related study activities. .The 
REDCap system will be programmed for skip patterns and out of range checks.  De-identified 
REDCap data will be immediately available to Tulane study staff who will run descriptives to 
check for aberrations, under the direction of Drs. Kissinger and Myers.  Any abnormalities will 
be discussed with the site staff during site calls or via email. Participants may be contacted by 
site staff to provide missing data or to clear up any inconsistencies in the data. Any data 
corrections will be logged and dated and reviewed at the monthly conference calls with sites.   
Individual ACASI/CAPI data files will be merged into databases by site and study visit (baseline, 
test of cure, 8 week). For analyses purposes, these databases will be merged into 
comprehensive SAS databases for index and partner levels.  Data will be stored on an 
encrypted Tulane server that is dedicated for study use only. 
 
13. ETHICS/PROTECTION OF HUMAN SUBJECTS 
 
 
13.1 Institutional Review Board/Ethics Committee 


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The study (i.e., protocol, consent forms, surveys, and study forms) will be reviewed by all IRBs 
associated with Tulane University and participating clinics which include University of 
Mississippi Medical Center, Mississippi State Department of Health, University of Alabama at 
Birmingham and Louisiana State University Health Sciences Center. No sites will start 
enrollment until Tulane IRB approval has been obtained. The study will not be implemented at 
any individual site until IRB approval has been received from that site and acknowledged by the 
Tulane University IRB.  
 
 
13.2 Informed Consent Process 
After the clinic provider refers a potential participant to the study staff, the study staff will provide 
a description of the study and what participation involves and check eligibility criteria. If a 
woman is eligible and interested in enrolling, informed consent will be obtained. Study staff, who 
are trained in consent procedures and have participated in an institutional human subjects 
protection course will obtain consent. First, there will be a more detailed discussion of what the 
study involves. Next, staff will review the consent form including the procedures, risks, and 
benefits that may be anticipated. Staff will answer any questions that the woman may have and 
make certain she understands that she does not have to be in the study if she chooses not to be 
and non-participation will not affect her care at the clinic. Non-English speakers are excluded 
from participation in this study. If a woman has a low literacy level, there is a provision and 
signature line that the consent form has been fully read to the participant. The consent form will 
be signed and a copy will be given to the participant. The subjects should have the opportunity 
to discuss the study with their surrogates or think about it prior to agreeing to participate.  The 
subjects may withdraw consent at any time throughout the course of the study.  A copy of the 
informed consent document will be given to the subjects for their records.  
A consent form template with suggested language for the clinical sites’ consent forms will be 
approved by Tulane IRB. Site specific consent forms will be IRB approved at the study site by 
their specific the clinical institution’s IRB (i.e. Louisiana State University Health Sciences Center, 
University of Mississippi Medical Center, the Mississippi State Department of Health and 
University of Alabama at Birmingham) and acknowledged by Tulane University IRB.  
 
13.2.1 Assent or Informed Consent Process (in Case of a 
Minor) 
 
  
N/A 
 
 
 
 
13.3 Exclusion of Women, Minorities, and Children (Special 
Populations) 


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Women and minorities are eligible for enrollment. Children less than 18 years of age are 
ineligible. This is a study of Trichomonas vaginalis which mainly affects an older, sexually active 
population. 
 
 
13.4 Participant Confidentiality 
Participant confidentiality is strictly held in trust by the participating investigators, their staff, and 
the sponsor and their agents.  This confidentiality is extended to cover testing of biological 
samples and genetic tests in addition to the clinical information relating to participating subjects. 
No names or identifying information such as addresses and phone numbers will be linked to 
study data. Clinical and laboratory staff will not have access to contact information collected by 
study staff. Contact information will only be used by the study coordinators or PIs to remind 
participants of appointments, reschedule appointments, or to notify them of any relevant 
changes to the study or information needed. All files will be kept in locked file cabinets with 
access limited to study staff. All databases will be password protected and kept on computers 
that are secure and accessible only by authorized study staff. Any data files that are emailed will 
be coded and encrypted. 
 
The study protocol, documentation, data and all other information generated will be held in strict 
confidence.  No information concerning the study or the data will be released to any 
unauthorized third party, without prior written approval of the sponsor. 
 
The study monitor or other authorized representatives of the sponsor may inspect all documents 
and records required to be maintained by the Investigator, including but not limited to, medical 
records (office, clinic or hospital as permitted by the clinical study site IRB) and pharmacy 
records for the participants in this study. Copies of CRFs will be transferred and stored at the 
Lead Site.    
 
 
13.5 Study Discontinuation 
 
In the event that the study is discontinued, participants can choose to continue care at the 
clinical site.  
 
14. DATA HANDLING AND RECORD KEEPING 
 
 
14.1 Data Management Responsibilities 
 


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The web based data system we will be using is REDCap (Vanderbilt University). The program 
will be used for web based data entry from clinics and laboratories. REDCap provides a high 
level of data privacy and security regarding data storage, transmission, backup, and access, as 
well as server protection. REDCap secure servers are registered with site certificates at Tulane 
University. The servers are stored in a locked, well-ventilated room in locked server 
cabinet/racks with 24/7 alarm security. Remote security is accomplished with Watchguard 
firewall hardware. Server backups are conducted daily. They are encrypted and streamed over 
on a private network to a secure offsite location. Access to data is available only to authorized 
personnel with specified username and password. Access privileges can be specified for each 
member of the research team with access to data, granting more or less access depending on 
their job description. All authorized personnel will be CITI certified for human subjects’ research. 
There are four different data that will be entered into the system: 
 
1 .  Provider assessment forms will be filled out by providers at each site, as permitted 
data will be abstracted by study staff and then data entered into REDCap. The 
encrypted database will only contain study identification numbers and dates of visits; 
they will not contain any other identifying data.  
2. 
Laboratory results will be entered into REDCap by study staff. Results may be delivered 
from the laboratory to study staff by email or courier. Participants will only be identified by 
their study numbers. These databases will be archived and merged into a single database 
for analyses purposes.  
3. Medication logs will be kept on site and follow guidelines of site pharmacies. These logs 
will contain medications distributed to participants and their partners. The logs will be 
reviewed during site visits by the PI and study coordinator. Copies of these logs may be 
provided to the Lead site. 
4. Contact data will be entered at the sites and will only be accessible to their site 
personnel, the Lead PI and Tulane study staff.  
All sites will transfer data to the data manager. The data manager at the study offices of Tulane 
University will be responsible for all data merging and cleaning. S/he will do routine review and 
cleaning of databases and provide feedback to site staff. S/he will maintain merged study 
databases and also create data coding dictionaries for all databases. These coding dictionaries 
will include variable names, types, and descriptions. This dictionary will be updated as needed. 
All databases will be reviewed quarterly by program manager and PI. Any discrepancies or 
errors will be discussed and resolved. Tulane study staff will also be responsible for producing 
monthly reports to investigators that include enrollment and other study statistics by site (blinded 
for randomization).  
All source documents and laboratory reports must be reviewed by the study and clinical staff at 
each site, who will ensure that they are accurate and complete. Adverse Events must be 
graded, assessed for severity and causality and reviewed by the site Principal Investigator or 


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study manager. Data collection is the responsibility of the clinical trial staff at the site under the 
supervision of the site Principal Investigator.  During the study, the Investigator will maintain 
complete and accurate documentation for the study. 
The analysis plan will be reviewed and revised by the PI and the Biostatistician. The analyses 
will be conducted by Tulane study staff under the direction and supervision of the PI with 
consultation with the Biostatistician. The PI will lead manuscript development and reporting. 
 
 
14.2 Data Capture Methods 
There will be five types of data collected: 
1.  Survey data: QDS software to create an ACASI survey. All data will automatically be entered 
into a database. In the event of computer complications, a paper survey will be available as a 
backup. If a paper survey is used, the data will be entered from the survey into the QDS 
software once the computer issue is resolved. Collection will be ongoing; data will be batched 
and sent to main study office at Tulane from site locations.  
2.  Contact information: Collected on paper and entered into REDCap. Collection will be on-
going and revised at follow up visits.  
3.  Provider form CRF: Collected on paper and entered into a REDCap database. Once entered, 
the paper copy will be kept in the study records. Collection will be on-going.  
4.  Laboratory data: Will be recorded on paper/electronic results forms and/ or entered directly 
into REDCap.  Gram stain results from LSUHSC lab will be de-identified and sent via email to 
study staff who will enter the results into REDCap 
5.  Adverse event CRF: Will be collected on paper and stored at the clinic offices. These forms 
will be on-going as events occur and sent to main study office via fax or electronic scan. Sent to 
main study office at Tulane from site locations 
 
 
14.3 Types of Data 
Behavioral, laboratory, clinical, and safety data will be collected. Safety data will be kept in the 
database with clinical data. 
 
 
14.4 Source documents and Access to Source Data/Documents 
Source data may include laboratory results, clinical records, contact forms and behavioral 
surveys. Research records will be housed at the four clinic sites and at the main study office at 


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Tulane University in the PI offices. Access to research records and data at each site will be 
limited to trained study personnel at each site (i.e. site investigators, site coordinators, research 
assistant) and Tulane study staff, under the direction and supervision of the PI during site visits. 
Access to research records and data at the main study offices will be limited to Tulane study 
staff and the Biostatistician under the direction and supervision of the PI. These records and 
data may also be accessed by members of the IRBs, DSMB, and an authorized representative 
of NIAID upon request. 
 
 
14.5 Timing/Reports 
Daily – data at each site will be reviewed by study coordinators for accuracy 
Weekly – data will be transferred to main study office and reviewed for accuracy by Tulane 
study staff under the direction and supervision of the PI. 
Monthly – conference calls will be held with the full research group to review enrollment 
statistics and study flow. Tulane study staff will create monthly reports to distribute to 
investigators under the direction and supervision of the PI.  
             -PI and program manager will review any safety reports 
Semiannually – The PI will provide reports to members of the DMSB which will include data on 
recruitment, randomization, adherence, adverse drug responses, as well as statistical tests and 
special analyses requested by the DSMB. 
Outcome data is measured at each visit. These data are monitored by site coordinators, data 
manager, program manager and PI. Data collection may be postponed or discontinued if severe 
unexpected adverse events occur. Coding of data will be ongoing. Data analysis will take place 
at the end of data collection when the randomization blind will be lifted.  
 
 
14.6 Study Records Retention 
At the end of the study, copies of the clinical sites’ CRFs and the archived contact database will 
be stored at the Tulane study office.  Clinical sites will retain their study folders. These records 
will be kept according to FDA and NIH requirements (whichever is longer). The PI will follow all 
mandates regarding records retention of NIAID and the participating institutions. 
 
 
14.7 Protocol Deviations 
Deviations from the IRB approved protocol are not allowed. Thorough monitoring of adherence 
to the study protocol will be maintained by investigators.  Any deviations will be reported to the 


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site PI, the Lead PI, the DSMB, the IRBs, NIAID and FDA the in the time frame and manner 
required by each institution. Corrective action will be taken. 
Since adherence to the study medication (metronidazole) is an outcome that will be evaluated 
by the study, missed doses will be documented but not considered a protocol deviation. It is 
preferred that that subjects on both arms take their first dose of medication under direct 
observation but it is not mandatory. If this happens, it will be documented in the study records, 
but is not considered a protocol deviation.  
 
A protocol deviation is any noncompliance with the clinical trial protocol, Good Clinical Practice 
(GCP), or Manual of Procedures requirements.  The noncompliance may be either on the part of 
the participant, the investigator, or the study site staff.  As a result of deviations, corrective 
actions are to be developed by the site and implemented promptly.  
 
These practices are consistent with Good Clinical Practice (GCP ICH E6) Sections: 
 
 
Compliance with Protocol, sections 4.5.1, 4.5.2, and 4.5.3 
 
Quality Assurance and Quality Control, section 5.1.1 
 
Noncompliance, sections 5.20.1, and 5.20.2. 
 
It is the responsibility of the site to use continuous vigilance to identify and report deviations 
according to the guidelines. 
 
 
15. PUBLICATION POLICY 
 
Publication of the results of this trial will be governed by NIAID publication policies.  Any 
presentation, abstract, or manuscript will be made available for review by the NIAID supporters 
prior to submission. 
 
 
Additional Considerations for the above section: 
Following completion of the study, the investigator may publish the results of this research in a 
scientific journal.  The International Committee of Medical Journal Editors (ICMJE) member 
journals have adopted a trials-registration policy as a condition for publication.  This policy 
requires that all clinical trials be registered in a public trials registry such as ClinicalTrials.gov, 
which is sponsored by the National Library of Medicine.   
 
 
 
 
 


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16.   SCIENTIFIC REFERENCES 
References: 
 
1. WHO. Global Prevalence and Incidence of Selected Curable Sexually Transmitted 
Infections. 2001. 
 
2. Cotch MF, Pastorek JG, 2nd, Nugent RP, et al. Trichomonas vaginalis associated with low 
birth weight and preterm delivery. The Vaginal Infections and Prematurity Study Group. Sex 
Transm Dis. Jul 1997;24(6):353-360. 
 
3. Swygard H, Sena AC, Hobbs MM, Cohen MS. Trichomoniasis: clinical manifestations, 
diagnosis and management. Sex Transm Infect. Apr 2004;80(2):91-95. 
 
4. McClelland RS, Sangare L, Hassan WM, et al. Infection with Trichomonas vaginalis 
increases the risk of HIV-1 acquisition. J Infect Dis. Mar 1 2007;195(5):698-702. 
 
5. Laga M, Manoka A, Kivuvu M, et al. Non-ulcerative sexually transmitted diseases as risk 
factors for HIV-1 transmission in women: results from a cohort study. Aids. Jan 
1993;7(1):95-102. 
 
6. Van Der Pol B, Kwok C, Pierre-Louis B, et al. Trichomonas vaginalis infection and human 
      immunodeficiency virus acquisition in African women. J Infect Dis. Feb 15 2008;197(4):548-   
      554.  
 
7. Gottlieb SL, Douglas JM, Jr., Foster M, et al. Incidence of herpes simplex virus type 2 
infection in 5 sexually transmitted disease (STD) clinics and the effect of HIV/STD risk-
reduction counseling. J Infect Dis. Sep 15 2004;190(6):1059-1067. 
 
8. Kissinger P, Amedee A, Clark RA, et al. Trichomonas vaginalis treatment reduces vaginal 
HIV-1 shedding. Sex Transm Dis. Jan 2009;36(1):11-16. 
 
9. Wang CC, McClelland RS, Reilly M, et al. The effect of treatment of vaginal infections on 
shedding of human immunodeficiency virus type 1. J Infect Dis. Apr 1 2001;183(7):1017-
1022. 
 
10. Boselli F, Chiossi G, Bortolamasi M, Gallinelli A. Prevalence and determinants of genital 
shedding of herpes simplex virus among women attending Italian colposcopy clinics. Eur J 
Obstet Gynecol Reprod Biol. Jan 10 2005;118(1):86-90. 
 
11. Kissinger P, Secor WE, Leichliter JS, et al. Early repeated infections with Trichomonas 
vaginalis among HIV-positive and HIV-negative women. Clin Infect Dis. Apr 1 
2008;46(7):994-999. 
 
12. Krashin JW, Koumans EH, Bradshaw-Sydnor AC, et al. Trichomonas vaginalis Prevalence,  
Incidence,Risk Factors and Antibiotic-Resistance in an Adolescent Population. Sex Transm 
Dis. Mar 26 2010. 


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13. Kissinger P, Schmidt N, Mohammed H, et al. Patient-delivered partner treatment for 
Trichomonas vaginalis infection: a randomized controlled trial. Sex Transm Dis. Jul 
2006;33(7):445-450. 
 
14. Tidwell BH, Lushbaugh WB, Laughlin MD, Cleary JD, Finley RW. A double-blind placebo-
controlled trial of single-dose intravaginal versus single-dose oral metronidazole in the 
treatment of trichomonal vaginitis. J Infect Dis. Jul 1994;170(1):242-246. 
 
15. Spence MR, Harwell TS, Davies MC, Smith JL. The minimum single oral metronidazole 
dose for treating trichomoniasis: a randomized, blinded study. Obstet Gynecol. May 
1997;89(5 Pt 1):699-703. 
 
16. Woodcock KR. Treatment of trichomonal vaginitis with a single oral dose of metronidazole. 
Br J Vener Dis. Feb 1972;48(1):65-68. 
 
17. Thin RN, Symonds MA, Booker R, Cook S, Langlet F. Double-blind comparison of a single 
dose and a five-day course of metronidazole in the treatment of trichomoniasis. Br J Vener 
Dis. Oct 1979;55(5):354-356. 
 
18. Hager WD, Brown ST, Kraus SJ, Kleris GS, Perkins GJ, Henderson M. Metronidazole for 
vaginal trichomoniasis. Seven-day vs single-dose regimens. Jama. Sep 12 
1980;244(11):1219-1220. 
 
19. duBouchet L, Spence MR, Rein MF, Danzig MR, McCormack WM. Multicenter comparison 
of clotrimazole vaginal tablets, oral metronidazole, and vaginal suppositories containing 
sulfanilamide, aminacrine hydrochloride, and allantoin in the treatment of symptomatic 
trichomoniasis. Sex Transm Dis. Mar 1997;24(3):156-160. 
 
20. Fleury FJ, Van Bergen WS, Prentice RL, Russell JG, Singleton JA, Standard JV. Single 
dose of two grams of metronidazole for Trichomonas vaginalis infection. Am J Obstet 
Gynecol. Jun 1 1977;128(3):320-323. 
 
21. CDC. Sexually Transmitted Diseases Treatment Guidelines, 2010. MMWR. 2010;59:RR-12. 
 
22. Kissinger P. A RANDOMIZED TREATMENT TRIAL: 2 Gram STAT Versus 7 DAY 500 MG 
BID DOSE of Metronidazole (MTZ) for the TREATMENT of Trichomonas Vaginalis AMONG 
HIV-Infected Women J Acquir Immune Defic Syndr 2010 Dec 15;55(5):565-571. 
 
23. Sobel JD. What's new in bacterial vaginosis and trichomoniasis? Infect Dis Clin North Am. 
Jun 2005;19(2):387-406. 
 
24. CDC. Expedited partner therapy in the management of sexually transmitted diseases. . 
2006. 
 


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25. Schwebke JR, Desmond RA. A randomized controlled trial of partner notification methods 
for prevention of trichomoniasis in women. Sex Transm Dis. Jun 2010;37(6):392-396. 
 
26. Sutton M, Sternberg M, Koumans EH, McQuillan G, Berman S, Markowitz L. The prevalence 
of Trichomonas vaginalis infection among reproductive-age women in the United States, 
2001-2004. Clin Infect Dis. Nov 15 2007;45(10):1319-1326. 
 
27. Csonka GW. Trichomonal vaginitis treated with one dose of metronidazole. Br J Vener Dis. 
Dec 1971;47(6):456-458. 
 
28. Aubert JM, Sesta HJ. Treatment of vaginal trichomoniasis. Single, 2-gram dose of 
metronidazole as compared with a seven-day course. J Reprod Med. Dec 1982;27(12):743-
745. 
 
29. CDC. Trichomoniasis Fact Sheet. 2007. 
 
30. Weinstock H, Berman S, Cates W, Jr. Sexually transmitted diseases among American 
youth: incidence and prevalence estimates, 2000. Perspect Sex Reprod Health. Jan-Feb 
2004;36(1):6-10. 
 
31. Krashin JW, Koumans EH, Bradshaw-Sydnor AC, et al. Trichomonas vaginalis Prevalence, 
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32. Cotch MF, Pastorek JG, 2nd, Nugent RP, Yerg DE, Martin DH, Eschenbach DA. 
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42. Allsworth JE, Ratner JA, Peipert JF. Trichomoniasis and other sexually transmitted 
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43. Lo M, Reid M, Brokenshire M. Epidemiological features of women with trichomoniasis in 
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44. Madhivanan P, Bartman MT, Pasutti L, et al. Prevalence of Trichomonas vaginalis infection 
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45. Garcia A, Exposto F, Prieto E, Lopes M, Duarte A, Correia da Silva R. Association of 
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46. Cherpes TL, Wiesenfeld HC, Melan MA, et al. The associations between pelvic inflammatory 
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47. Paisarntantiwong R, Brockmann S, Clarke L, Landesman S, Feldman J, Minkoff H. The 
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51. Mann JR, McDermott S, Barnes TL, Hardin J, Bao H, Zhou L. Trichomoniasis in pregnancy 
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52. Schwandt A, Williams C, Beigi RH. Perinatal transmission of Trichomonas vaginalis: a case 
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53. Carter JE, Whithaus KC. Neonatal respiratory tract involvement by Trichomonas vaginalis: a 
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54. Temesvari P, Kerekes A, Tege A, Szarka K. Demonstration of Trichomonas vaginalis in 
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55. Kigozi GG, Brahmbhatt H, Wabwire-Mangen F, et al. Treatment of Trichomonas in 
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56. Klebanoff MA, Carey JC, Hauth JC, et al. Failure of metronidazole to prevent preterm 
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57. Ghys PD, Diallo MO, Ettiegne-Traore V, et al. Genital ulcers associated with human 
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58. ter Meulen J, Mgaya HN, Chang-Claude J, et al. Risk factors for HIV infection in 
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59. TV, Khuu NV, Truong PH, Nguyen AP, Truong LX, Detels R. Correlation between HIV and 
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60. Sardana S, Sodhani P, Agarwal SS, et al. Epidemiologic analysis of Trichomonas vaginalis 
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61. Levine WC, Pope V, Bhoomkar A, et al. Increase in endocervical CD4 lymphocytes among 
women with nonulcerative sexually transmitted diseases. J Infect Dis. Jan 1998;177(1):167-
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62. Guenthner PC, Secor WE, Dezzutti CS. Trichomonas vaginalis-induced epithelial monolayer 
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63. Moodley P, Connolly C, Sturm AW. Interrelationships among human immunodeficiency virus 
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64. van de Wijgert JH, Morrison CS, Brown J, et al. Disentangling contributions of reproductive 
tract infections to HIV acquisition in African Women. Sex Transm Dis. Jun 2009;36(6):357-
364. 
 
65. Sorvillo F, Kerndt P. Trichomonas vaginalis and amplification of HIV-1 transmission. Lancet.  
Jan 17 1998;351(9097):213-214 
 
66. Chesson HW, Blandford JM, Pinkerton SD. Estimates of the annual number and cost of new 
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67. McClelland RS. Trichomonas vaginalis infection: can we afford to do nothing? J Infect Dis. 
Feb 15 2008;197(4):487-489. 
 
68. Price MA, Stewart SR, Miller WC, et al. The cost-effectiveness of treating male 
trichomoniasis to avert HIV transmission in men seeking sexually transmitted disease care 
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69. Sorvillo F, Smith L, Kerndt P, Ash L. Trichomonas vaginalis, HIV, and African-Americans. 
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70. Schwebke JR, Barrientes FJ. Prevalence of Trichomonas vaginalis isolates with resistance 
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71. Perez S, Fernandez-Verdugo A, Perez F, Vazquez F. Prevalence of 5-nitroimidazole-
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72. Schmid G, Narcisi E, Mosure D, Secor WE, Higgins J, Moreno H. Prevalence of 
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73. Forna, F. and A. M. Gulmezoglu (2003). Interventions for treating trichomoniasis in women. 
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74. Schwebke JR and Desmond RA. Tinidazole versus Metronidazole for the Treatment of 
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75. Harris KJ, Golbeck AL, Cronk NJ, Catley D, Conway K, Williams KB. Timeline follow-back 
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76. Magnus M, Clark R, Myers L, Farley T, Kissinger PJ. Trichomonas vaginalis among HIV-
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77. Niccolai LM, Kopicko JJ, Kassie A, Petros H, Clark RA, Kissinger P. Incidence and 
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79. Allsworth JE, Peipert JF. Prevalence of bacterial vaginosis: 2001-2004 National Health and 
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Site Roster 
 
SITE INVESTIGATOR-PRINCIPAL 
Patricia Kissinger, PhD 
Epidemiologist/Professor 
Tulane University SPHTM 
1440 Canal St, SL-18 
New Orleans, LA 70112 
Phone: (504) 988-7320 
Fax: (504) 988-1568 
Email:kissing@tulane.edu 
 
Site Study Coordinator New Orleans 
 
 
Site study Coordinator Jackson 
Jennifer Brumfield, RN, MHS 
 
Site study Coordinator Birmingham 
Saralyn Richter, RN, MSN 
Hanne Harbison, NP 
 
 
 
NIAID PROGRAM OFFICER 
Hagit David, Ph.D.  
Product Development Program Officer  
Sexually Transmitted Infections Branch  
DMID/NIAID/NIH/DHHS Room 5026  
6610 Rockledge Drive  
Phone: (301) 402-4596  
Fax: (301) 480-3617  
Bethesda, MD 20892-6604  
HDavid@niaid.nih.gov 
 
SITE PRINCIPAL-INVESTIGATOR  
Leandro Mena, MD, MPH 
Medical Director 
Crossroads Clinic 
3315 Woodrow Wilson Blvd 
Jackson, MS 39216 
Phone: (601) 984-5560 
Fax: (601) 815-4014   
Email:lmena@umc.edu 
 
 
SITE PRINCIPAL INVESTIGATOR                                 
Christina Muzny, MD 
University of Alabama at Birmingham 
1802 6th Av S 
Birmingham, AL 35233 
Phone: (205) 975-3298 
Fax: (205) 975-7764 
Email: cmuzny@uab.edu 
 
SITE CO-INVESTIGATOR                                 
Jane Schwebke, MD 
University of Alabama at Birmingham 
1802 6th Av S 
Birmingham, AL 35233 
Phone: (205) 975-5665 
Fax: (205) 975-7764 
Email: schwebke@uab.edu 
 
 
 
SITE PRINCIPAL-INVESTIGATOR  
Rebecca Lillis, MD 
Assistant Professor, Assistant Director 
CrescentCare Health and Wellness 
3308 Tulane Avenue, New Orleans, LA 70119 
Phone: (504) 207-2273 
Fax (504) 568-2416 
Email: rlilli@lsuhsc.edu 
 
SITE CO-INVESTIGATOR  
Stephanie Taylor, MD 
Medical Director 
CrescentCare Health and Wellness 
3308 Tulane Avenue, New Orleans, LA 70119 
Phone: (504) 207-2273 
Fax (504) 568-2416 
Email: staylo2@lsuhsc.edu 
 
 
 
PROJECT MANAGER 
Norine  Schmidt, MPH 
Tulane University SPHTM 
1440 Canal St, Suite 2006 
New Orleans, LA 70112 
Phone (504) 988-8268 
Fax: (504) 988-1568 
Email:nschmid1@tulane.edu 
 
 
 
 
Medical/Laboratory Co-Investigator(s):  
 
David H Martin, MD 
Tulane University – Department of Epidemiology 
1440 Canal St, Suite 2006 
New Orleans  LA  70112 
Phone: (504) 568-5031 
Fax: (504) 568-8825 
Email: dmarti6@tulane.edu 
 
Jane Carlton, PhD 
Director, Center for Genomics and Systems 
Biology 
New York University 
12 Waverly Place, Rm 506 
New York, NY 10003 
Phone: (212) 992-6981 
Email: jane.carlton@nyu.edu 
 
Data Coordinating Center Contact (example,  
data manager, biostatistician) 
Dr. Leann Myers 
Biostatistician/Professor 
Tulane University SPHTM 
1440 Canal Street 
New Orleans, LA 70112 
Phone: (504) 988-7845 
Email: myersl@tulane.edu