Conditions: HIV Infections
Keywords: HIV Immune failure Tocilizumab ACTEMRA Antiretroviral therapy HAART
Allocation: RANDOMIZED | Intervention model: CROSSOVER
Enrollment: 34
Healthy volunteers: no

Brief summary:
The study is a phase I/II, double-blind, placebo-controlled, randomized cross-over clinical trial of tocilizumab (TCZ) or placebo in HIV-infected subjects receiving antiretroviral therapy with suppressed viral replication and CD4+ T cell count ≥350 and ≤1,000 cells/mm3)

Detailed description:
DESIGN The study is a phase I/II, double-blind, placebo-controlled, randomized cross-over clinical trial of tocilizumab (TCZ) or placebo in HIV-infected subjects receiving antiretroviral therapy with suppressed viral replication and CD4+ T cell count ≥350 and ≤1,000 cells/mm3)

DURATION 40 weeks during cross-over treatment periods total per subject.

SAMPLE SIZE 30 subjects with complete data up to week 30. Up to 36 subjects may be enrolled in order to achieve an estimated final sample size of 30 participants with complete data up to week 30.

POPULATION HIV-infected male and female subjects from 18 through 60 years of age receiving combination antiretroviral therapy (ART) without changes in the 24 weeks prior to enrollment (changes for reasons other than virologic failure allowed up to 8 weeks prior to enrollment), with a suppressed plasma HIV RNA (\<200 copies/mL, one blip up to \<1,000 copies/mL permitted) for at least 96 weeks and a CD4+ T-cell count ≥350 and ≤1,000 cells/mm3 at the time of study enrollment.

REGIMEN Subjects will be randomized 1:1 to one of the following arms:

ARM A: TCZ, 4 mg/Kg by IV infusion over 60 minutes (not to exceed 400 mg) once at study entry, followed by TCZ, 8 mg/Kg by IV infusion over 60 minutes (not to exceed 800 mg) at weeks 4, and 8 and THEN placebo by IV infusion at weeks 20, 24, and 28.

ARM B: Placebo by IV infusion at study entry followed by placebo by IV infusion at weeks 4 and 8, and THEN TCZ, 4 mg/Kg (not to exceed 400 mg) by IV infusion over 60 minutes once at week 24, followed by TCZ, 8 mg/Kg (not to exceed 800 mg) by IV infusion over 60 minutes at weeks 24 and 28.

Arms:
arm 1: ARM A: TCZ, 4 mg/Kg by IV infusion over 60 minutes (not to exceed 400 mg) once at study entry, followed by TCZ, 8 mg/Kg by IV infusion over 60 minutes (not to exceed 800 mg) at weeks 4 and 8, and THEN placebo by IV infusion at weeks 20, 24, and 28. arm 2: ARM B: Placebo by IV infusion at study entry followed by placebo by IV infusion at weeks 4 and 8, and THEN TCZ, 4 mg/Kg (not to exceed 400 mg) by IV infusion over 60 minutes once at week 20, followed by TCZ, 8 mg/Kg (not to exceed 800 mg) by IV infusion over 60 minutes at weeks 24 and 28.

Interventions: intervention 1: tocilizumab intervention 2: Placebo
Intervention descriptions: intervention 1: Subjects will be randomized 1:1 to one of the following arms:

ARM A: TCZ, 4 mg/Kg by IV infusion over 60 minutes (not to exceed 400 mg) once at study entry, followed by TCZ, 8 mg/Kg by IV infusion over 60 minutes (not to exceed 800 mg) at weeks 4 and 8, and THEN placebo by IV infusion at weeks 20, 24, and 28.

ARM B: Placebo by IV infusion at study entry followed by placebo by IV infusion at weeks 4 and 8, and THEN TCZ, 4 mg/Kg (not to exceed 400 mg) by IV infusion over 60 minutes once at week 20, followed by TCZ, 8 mg/Kg (not to exceed 800 mg) by IV infusion over 60 minutes at weeks 24 and 28. intervention 2: Subjects will be randomized 1:1 to one of the following arms:

ARM A: TCZ, 4 mg/Kg by IV infusion over 60 minutes (not to exceed 400 mg) once at study entry, followed by TCZ, 8 mg/Kg by IV infusion over 60 minutes (not to exceed 800 mg) at weeks 4 aned 8, and THEN placebo by IV infusion at weeks 20, 24, and 28.

ARM B: Placebo by IV infusion at study entry followed by placebo by IV infusion at weeks 4 and 8, and THEN TCZ, 4 mg/Kg (not to exceed 400 mg) by IV infusion over 60 minutes once at week 20, followed by TCZ, 8 mg/Kg (not to exceed 800 mg) by IV infusion over 60 minutes at weeks 24 and 28.

Protocol document:
Prot_SAP_000.pdf: 
 
 
 
 
 
 
AIDS 347 
 
IL-6 Blockade in Treated HIV Infection 
 
Funded by: 
Division of AIDS, US National Institute of Allergy and Infectious Diseases 
US National Institutes of Health 
 
NIAID Funding Mechanism: U01-AI-105937-01 
DAIDS Protocol Number: 11946 
 
 
 
IND Holder and Sponsor: Benigno Rodriguez, MD 
Study Phase: I/II 
This protocol will be performed under the following IND#: 121325 
 
 
 
 
 
Protocol Co-Chairs:  
Benigno Rodriguez, MD 
 
Michael M. Lederman, MD 
 
 
Study Coordinator: 
 
 
Jane Baum, RN 
 
 
 
 
 
 
 
 
 
FINAL Version 4.0 
March 12th, 2015 
 
 


 
CONTENTS 
SITES PARTICIPATING IN THE STUDY ..................................................................................................... 7 
PROTOCOL TEAM ROSTER ....................................................................................................................... 8 
STUDY MANAGEMENT .............................................................................................................................. 10 
GLOSSARY OF ABBREVIATIONS ........................................................................................................... 11 
INVESTIGATOR SIGNATURE FORM ............................................................................................................ 14 
SCHEMA ....................................................................................................................................................... 15 
DESIGN .......................................................................................................................................................... 15 
DURATION .................................................................................................................................................... 15 
SAMPLE SIZE ............................................................................................................................................... 15 
POPULATION ............................................................................................................................................... 15 
REGIMEN....................................................................................................................................................... 15 
1.0 
HYPOTHESES AND STUDY OBJECTIVES .................................................................................. 16 
1.1 
HYPOTHESES ....................................................................................................................................... 16 
1.2 
PRIMARY OBJECTIVES ........................................................................................................................ 16 
1.3 
SECONDARY OBJECTIVES ................................................................................................................... 16 
2.0 
INTRODUCTION ............................................................................................................................... 19 
2.1 
BACKGROUND AND RATIONALE FOR BLOCKING IL-6 AS A THERAPEUTIC STRATEGY IN IMMUNE 
FAILURE 
19 
2.1.1 
Immune Failure and Immune Success with Antiretroviral Therapy ................................... 19 
2.1.2  
Role of Immune Activation/Inflammation and Coagulation in HIV Disease. .................... 19 
2.1.3  
Inflammatory Markers also Predict Mortality in Treated HIV-1 Infection. ......................... 20 
2.1.4  
Interleukin-6 and its Potential Role in Immune Failure ....................................................... 21 
2.1.5  
IL-6 May Block Cellular Restoration in Immune Failure by Decreasing Expression of the 
IL-7 Receptor α Chain (CD127). .................................................................................................................... 22 
2.1.6  
HIV Replication does not Appear to Be a Major Determinant of IL-6 Expression and IL-6 
Levels in Plasma Remain Elevated despite ARV-induced Control of HIV Replication. ......................... 22 
2.1.7  
The Gut May Be a Major Source of the Elevated IL-6 Levels in Treated HIV Infection. 22 
2.1.8  
Increased Gut Mucosal Expression of IL-6 in HIV Infection May Be both Cause and 
Consequence of Microbial Translocation...................................................................................................... 23 
2.1.9 
Expression of the IL-7 Receptor Alpha Chain (CD127) May Be Necessary to Maintain 
the Frequency and Survival of Gut T Cells and ILC that Sustain Mucosal Integrity and Barrier 
Function. 
24 
2.1.10 
Cardiovascular Risk in Treated HIV Infection, the Role of Inflammation and IL-6 .......... 24 
2.1.11 
Other Proposed Interventions to Manage Inflammation in HIV Infection ......................... 25 
2.2 
RATIONALE .......................................................................................................................................... 25 
2.2.1 
Rationale for the Choice of Study Agent ............................................................................... 25 
2.2.2 
Safety of TCZ ............................................................................................................................ 26 
2.2.2.1 
Serious Infections ................................................................................................................................ 27 
2.2.2.2 
Hypersensitivity Reactions.................................................................................................................. 27 
2.2.2.3 
Gastrointestinal Perforations .............................................................................................................. 27 
2.2.2.4 Infusion Reactions ..................................................................................................................................... 28 
2.2.2.5 Laboratory Abnormalities ......................................................................................................................... 28 
2.2.2.5.1 
Neutropenia ................................................................................................................................... 28 
2.2.2.5.2 
Thrombocytopenia ........................................................................................................................ 29 
2.2.2.5.3 
Liver Enzyme Elevations .............................................................................................................. 29 
2.2.2.5.4 
Lipid Elevations ............................................................................................................................. 30 
2.2.2.6 
Malignancies ......................................................................................................................................... 31 
2.2.2.7 
Viral Reactivation ................................................................................................................................. 31 


 
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2.2.2.8 
Cytochrome P450 Inhibition and Decreased Plasma Levels of Antiretrovirals ........................... 33 
2.2.2.9 
Demyelinating Disorders ..................................................................................................................... 33 
2.2.2.10 
Immunogenicity.................................................................................................................................... 33 
2.2.2.11 
Safety of TCZ in HIV-infected Individuals ........................................................................................ 34 
2.2.3  
Rationale for Rectosigmoid Biopsies ..................................................................................... 34 
2.2.3.1 
Risks of Rectosigmoid Biopsy ............................................................................................................ 35 
2.2.4  
Rationale for Study Population ............................................................................................... 36 
2.2.5 
Rationale for Inclusion of Women of Reproductive Potential ............................................. 37 
2.2.6 
Rationale for a Crossover Design .......................................................................................... 38 
2.2.7 
Rationale for Duration of Study .............................................................................................. 38 
3.0 
STUDY DESIGN ................................................................................................................................ 38 
4.0 
SELECTION AND ENROLLMENT OF SUBJECTS ...................................................................... 39 
4.1 
INCLUSION CRITERIA ........................................................................................................................... 39 
4.2 
EXCLUSION CRITERIA .......................................................................................................................... 42 
4.3 
STUDY ENROLLMENT PROCEDURES ................................................................................................... 45 
4.3.1 
Study Initiation ........................................................................................................................... 45 
4.3.2 
Recruitment ............................................................................................................................... 45 
4.3.3 
Subject Registration ................................................................................................................. 46 
4.3.4 
Retention .................................................................................................................................... 46 
4.4 
COENROLLMENT GUIDELINES ............................................................................................................. 46 
5.0 
STUDY TREATMENT ....................................................................................................................... 47 
5.1 
REGIMENS, ADMINISTRATION, AND DURATION................................................................................... 47 
5.2 
STUDY PRODUCT FORMULATION AND PREPARATION ........................................................................ 47 
5.3 
PHARMACY: PRODUCT SUPPLY, DISTRIBUTION, AND ACCOUNTABILITY .......................................... 48 
5.3.1 
Study Product Acquisition/Distribution .................................................................................. 48 
5.3.2 
Study Product Accountability .................................................................................................. 48 
5.3.3 
Storage ....................................................................................................................................... 48 
5.3.4  
Administration ........................................................................................................................... 48 
5.3.5 
Dispensing ................................................................................................................................. 49 
5.3.6 
Retrieval of Unused Product ................................................................................................... 49 
5.4 
CONCOMITANT MEDICATIONS ............................................................................................................. 49 
5.4.1 
Prohibited Medications ............................................................................................................ 49 
6.0 
CLINICAL AND LABORATORY EVALUATIONS ......................................................................... 50 
6.1 
SCHEDULE OF EVENTS ........................................................................................................................ 50 
6.2 
TIMING OF EVALUATIONS .................................................................................................................... 51 
6.2.1 
Overview of Study Visits .......................................................................................................... 51 
6.2.2 
Visit 1: Screening Evaluations (Day -60 to -10) ................................................................... 51 
6.2.3  
Visit 2: Baseline Evaluations (Day -10 to 0) ......................................................................... 52 
6.2.4    Visit 3: Study Entry (Day 0) ........................................................................................................ 53 
6.2.5 
Visit 4: Day 3 (+/-1 day) ........................................................................................................... 54 
6.2.6 
Visit 5: Week 4 (+/-4 days) ...................................................................................................... 55 
6.2.7 
Visit 6: Week 8 (+/-4 days) ...................................................................................................... 56 
6.2.8 
Visit 7: Week 10 (+/-4 days) .................................................................................................... 56 
6.2.9  
Visit 8: Week 20 Crossover (+/- 7 days) ............................................................................... 57 
6.2.10 
Visit 9: Week 20 and 3 Days (+/- 1 day) ............................................................................... 59 
6.2.11 
Visit 10: Week 24 (+/-4 days) .................................................................................................. 59 
6.2.12 
Visit 11: Week 28 (+/-4 days) .................................................................................................. 60 
6.2.13 
Visit 12: Week 30 (+/-4 days) .................................................................................................. 60 


 
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6.2.14 
Visit 13 (End of Study): Week 40 (+/- 7 days) ...................................................................... 61 
6.2.15 
Interim Contacts and Visits ..................................................................................................... 62 
6.2.16 
Participants Who Become Pregnant ...................................................................................... 62 
6.2.17 
Discontinuation Evaluations .................................................................................................... 63 
6.2.17.1 
Final Contact ........................................................................................................................................ 63 
6.2.17.2 
Evaluations for Registered Subjects Who Do Not Start Study Treatment .................................. 63 
6.2.17.3 
Premature Study Treatment Discontinuation Evaluations ............................................................. 63 
6.2.17.4 
Premature Study Discontinuation Evaluations ................................................................................ 63 
6.3 
INSTRUCTIONS FOR EVALUATIONS ..................................................................................................... 64 
6.3.1 
Documentation of HIV .............................................................................................................. 65 
6.3.2 
Medical History ......................................................................................................................... 65 
6.3.3 
Medication History .................................................................................................................... 65 
6.3.4 
Clinical Assessments ............................................................................................................... 65 
6.3.4.1 
Complete Physical Exam .................................................................................................................... 65 
6.3.4.2 
Targeted Physical Exam ..................................................................................................................... 65 
6.3.4.3 
Additional Vital Sign Monitoring at Study Agent Administration Visits .......................................... 66 
6.3.4.4 
Height .................................................................................................................................................... 66 
6.3.4.5 
Weight .................................................................................................................................................... 66 
6.3.4.6 
Signs and Symptoms........................................................................................................................... 66 
6.3.4.7 
Diagnoses ............................................................................................................................................. 66 
6.3.4.8 
Concomitant Medications.................................................................................................................... 66 
6.3.4.9 
Study Treatment Modifications........................................................................................................... 66 
6.3.4.10 
Antiretroviral Medications ................................................................................................................... 67 
6.3.5 
Laboratory Evaluations ............................................................................................................ 67 
6.3.5.1 
Clinical Laboratory Tests .................................................................................................................... 67 
6.3.5.2 
Pharmacologic Studies ....................................................................................................................... 68 
6.3.5.2.1 
Tocilizumab levels......................................................................................................................... 68 
6.3.5.2.2 
Antiretroviral Level Monitoring ..................................................................................................... 68 
6.3.5.3 
Transcriptomic Studies ........................................................................................................................ 69 
6.3.5.4 
Metabolic Studies ................................................................................................................................. 69 
6.3.5.4.1 
Lipid fractions and other markers of cardiovascular risk ......................................................... 69 
6.3.5.4.2 
Metabolomic profile ....................................................................................................................... 69 
6.3.5.5 
Immunologic Studies ........................................................................................................................... 70 
6.3.5.6 
Cardiovascular Studies (BART testing) ............................................................................................ 71 
6.3.5.7 
Sigmoidoscopy and Biopsies ............................................................................................................. 71 
6.4 
SPECIMEN COLLECTION, HANDLING, AND PROCESSING ................................................................... 72 
6.4.1  
General Specimen Management Guidance ......................................................................... 72 
6.4.2 
Storage of Specimens for Future Use ................................................................................... 72 
7.0 
CLINICAL MANAGEMENT ISSUES ............................................................................................... 73 
7.1 
MANAGEMENT OF SPECIFIC ADVERSE EVENTS ................................................................................. 73 
7.1.1 
Serious Infections ..................................................................................................................... 73 
7.1.2 
Acute Hypersensitivity Reactions ........................................................................................... 73 
7.1.3 
Gastrointestinal Perforation..................................................................................................... 74 
7.1.4 
Infusion Reactions .................................................................................................................... 74 
7.1.5 
Laboratory Abnormalities......................................................................................................... 74 
7.1.5.1 
Neutropenia .......................................................................................................................................... 74 
7.1.5.2 
Thrombocytopenia ............................................................................................................................... 75 
7.1.5.3 
AST and ALT Abnormalities ............................................................................................................... 75 
7.1.5.3.1 
AST or ALT >1.4 to 3 Times the Upper Limit of Normal .......................................................... 75 
7.1.5.3.2 
AST or ALT ˃3 to 5 Times the Upper Limit of Normal ............................................................. 75 
7.1.5.3.3 
Liver Enzymes ˃5 Times the Upper Limit of Normal ............................................................... 76 
7.1.5.4 
Lipid Abnormalities .............................................................................................................................. 76 
7.1.6 
Malignant Conditions ................................................................................................................ 76 
7.1.7 
Viral Reactivation ...................................................................................................................... 76 


 
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7.1.8 
Cytochrome P450 Inhibition and Decreased Plasma Levels of Antiretrovirals ............... 76 
7.1.9 
Demyelinating Conditions ........................................................................................................ 77 
7.2 
MANAGEMENT OF OTHER ADVERSE EVENTS ..................................................................................... 77 
7.2.1 
Grade 1 or 2 AE ........................................................................................................................ 77 
7.2.2 
Grade 3 AE ................................................................................................................................ 77 
7.2.3 
Grade 4 AE ................................................................................................................................ 78 
7.3 
RESUMPTION OF STUDY TREATMENT ADMINISTRATION WHEN THE CROSSOVER DOSE IS HELD .... 78 
7.4 
PREGNANCY ........................................................................................................................................ 78 
7.5 
REPORTING OF ADVERSE REACTIONS TO THE RESPONSIBLE IRBS ................................................. 78 
7.6 
SOCIAL HARMS REPORTING ............................................................................................................... 79 
8.0 
CRITERIA FOR DISCONTINUATION ............................................................................................. 79 
8.1 
PERMANENT TREATMENT DISCONTINUATION .................................................................................... 79 
8.2 
PREMATURE STUDY DISCONTINUATION ............................................................................................. 80 
8.3 
TEMPORARY TREATMENT DISCONTINUATION .................................................................................... 81 
8.4 
CRITERIA FOR UNBLINDING ................................................................................................................. 81 
9.0 
STATISTICAL CONSIDERATIONS ................................................................................................ 81 
9.1 
DESIGN AND PRIMARY ENDPOINTS ..................................................................................................... 81 
9.1.1 
Primary Endpoint 1 (Safety) .................................................................................................... 81 
9.1.2 
Primary Endpoint 2 (Inflammation) ........................................................................................ 82 
9.1.3 
Primary Endpoint 3 (Cellular Cycling) .................................................................................... 82 
9.2 
STATISTICAL ANALYSIS ...................................................................................................................... 82 
9.2.1. 
Baseline Comparability ............................................................................................................ 82 
9.2.2 
Safety Analysis ......................................................................................................................... 82 
9.2.3 
Primary Analysis of Two Co-Primary Endpoints .................................................................. 82 
9.2.4 
Secondary Safety Analyses .................................................................................................... 83 
9.2.5 
Secondary Analyses of Two Co-Primary Endpoints ........................................................... 83 
9.2.6 
Adjustment for Baseline Covariates Measured prior to Randomization ........................... 83 
9.2.7 
Carry-over Effects ..................................................................................................................... 84 
9.2.8 
Multiplicity .................................................................................................................................. 84 
9.2.9 
Missing Data .............................................................................................................................. 84 
9.3 
SAMPLE SIZE JUSTIFICATION .............................................................................................................. 85 
9.3.1 
Sample Size Considerations for Safety ................................................................................. 85 
9.3.2 
Sample Size Considerations for Inflammation and Cellular Cycling ................................. 85 
9.3.3 
Accrual and Loss to Follow-up ............................................................................................... 86 
9.4 
MONITORING ........................................................................................................................................ 87 
10.0 PHARMACOLOGY PLAN ................................................................................................................... 88 
11.0 DATA COLLECTION AND MONITORING AND ADVERSE EVENT REPORTING ...................... 89 
11.1 RECORDS TO BE KEPT ........................................................................................................................... 89 
11.2 STUDY COORDINATION ........................................................................................................................... 89 
11.3 CLINICAL SITE MONITORING AND RECORD AVAILABILITY .................................................................... 90 
11.4 ADVERSE EVENT REPORTING ................................................................................................................ 90 
11.4.1 
Definitions .................................................................................................................................. 90 
11.4.1.1  
Adverse event (AE) ................................................................................................................................. 90 
11.4.1.2 
Adverse Reaction .................................................................................................................................... 91 
11.4.1.3 
Suspected ............................................................................................................................................... 91 
11.4.1.4 
Unexpected ............................................................................................................................................ 91 
11.4.1.5 
Serious .................................................................................................................................................... 92 
11.4.1.6 
Life-Threatening ..................................................................................................................................... 92 


 
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11.4.2 
Expedited Adverse Event Reporting to the DAIDS Medical Officer .............................................. 92 
11.4.3 
Reporting to the University Hospitals of Cleveland Case Medical Center (UHCMC) Institutional 
Review Board (IRB) .............................................................................................................................................. 92 
11.4.4 
Expedited Reporting to the Food and Drug Administration and the DAIDS Medical Officer ....... 93 
11.4.5 
Reporting Requirements for this Study ........................................................................................ 93 
11.4.6 
Grading Severity of Events .......................................................................................................... 94 
11.4.7 
Relationship to Study Agent ........................................................................................................ 94 
11.4.8 
Expedited AE Reporting Period .................................................................................................... 94 
11.4.9 
Reporting Procedures .................................................................................................................. 94 
12.0 HUMAN SUBJECTS ............................................................................................................................ 95 
12.1 IRB REVIEW AND INFORMED CONSENT ................................................................................................. 95 
12.2 SUBJECT CONFIDENTIALITY ................................................................................................................... 95 
12.3 STUDY DISCONTINUATION ...................................................................................................................... 95 
12.4 HUMAN SUBJECTS INVOLVEMENT, CHARACTERISTICS, AND DESIGN .................................................. 96 
12.5. SOURCES OF MATERIALS ...................................................................................................................... 96 
12.6 POTENTIAL RISKS AND RISK MITIGATION STRATEGIES ........................................................................ 97 
12.6.1  
Risks of Tocilizumab ................................................................................................................ 97 
12.6.1.1 
Risk Mitigation Strategy for Serious Infections................................................................................ 97 
12.6.1.2 
Risk Mitigation Strategy for Hypersensitivity Reactions ................................................................. 97 
12.6.1.3 
 Risk Mitigation Strategy for Gastrointestinal Perforations ............................................................ 98 
12.6.1.4 
Risk Mitigation Strategy for Infusion Reactions .............................................................................. 98 
12.6.1.5 
Risk Mitigation Strategy for Laboratory Abnormalities ................................................................... 98 
12.6.1.5.1 
Neutropenia ................................................................................................................................. 98 
12.6.1.5.2 
Thrombocytopenia ...................................................................................................................... 99 
12.6.1.5.3 
AST and ALT Abnormalities ...................................................................................................... 99 
12.6.1.5.4 
Lipid abnormalities ...................................................................................................................... 99 
12.6.1.6 
Risk Mitigation Strategy for Malignancies ...................................................................................... 100 
12.6.1.7 
Risk Mitigation Strategy for Viral Reactivation .............................................................................. 100 
12.6.1.8 
Risk Mitigation Strategy for Cytochrome P450 Inhibition and Decreased Plasma Levels of 
Antiretrovirals 100 
12.6.1.9 
Risk Mitigation Strategy for Demyelinating Disorders .................................................................. 101 
12.6.1.10Risk Mitigation Strategy for Women of Reproductive Potential ..................................................... 101 
12.6.2 
Enemas (for the subset of participants agreeing to rectal biopsies) ............................... 102 
12.6.3 
Flexible Sigmoidoscopy and Biopsies ................................................................................. 102 
12.6.4 
Intravenous Infusion ............................................................................................................... 102 
12.6.5 
Blood Sample Collection ....................................................................................................... 102 
12.7 ADEQUACY OF PROTECTION AGAINST RISKS ...................................................................................... 103 
12.7.1 
Recruitment and Informed Consent ..................................................................................... 103 
12.7.2 
Protections against Specific Study-related Risks .............................................................. 103 
12.8 POTENTIAL BENEFITS OF THE PROPOSED RESEARCH TO HUMAN SUBJECTS AND OTHERS ............ 103 
12.9 IMPORTANCE OF THE KNOWLEDGE TO BE GAINED ............................................................................. 103 
12.10 DATA AND SAFETY MONITORING PLAN ............................................................................................. 104 
12.11 CLINICALTRIALS.GOV REQUIREMENTS .............................................................................................. 104 
12.12 INCLUSION OF WOMEN AND MINORITIES ........................................................................................... 104 
12.13 INCLUSION OF CHILDREN ................................................................................................................... 104 
13.0 PUBLICATION OF RESEARCH FINDINGS ................................................................................... 104 
14.0 BIOHAZARD CONTAINMENT ......................................................................................................... 104 
15.0 REFERENCES ................................................................................................................................... 105 


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


 
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PROTOCOL TEAM ROSTER 
 
Co-Chairs 
 
Benigno Rodriguez, MD 
2061 Cornell Road, Suite 401 
Cleveland, OH 44106 
Phone: (216) 844-2057 
Fax: (216) 844-5523 
E-Mail: rodriguez.benigno@clevelandactu.org  
 
 
Michael M. Lederman, MD 
2061 Cornell Road, Suite 401 
Cleveland, OH 44106 
Phone: (216) 844-8786 
Fax: (216) 844-5523 
E-Mail: MXL6@case.edu 
 
Study Coordinator 
 
Jane Baum, RN BSN 
2061 Cornell Road, Suite 301C 
Cleveland, OH 44106 
Phone: (216) 844-2546 
Fax: (216) 844-5523 
E-Mail: baum.jane@clevelandactu.org  
 
Data Manager 
 
Preeti Tuscano 
Case Western Reserve University 
2061 Cornell Road, Suite 307 
Cleveland, OH 44106 
Phone: 216-844-3605 
E-Mail: Tuscano.Preeti@clevelandactu.org 
 
Research Nurses 
 
Kristen Allen, RN BSN 
2061 Cornell Road, Suite 301D 
Cleveland, OH 44106 
Phone: (216) 844-8136 
Fax: (216) 844-5523 
E-Mail: allen.kristen@clevelandactu.org  
 
 
Patricia Walton, RN BSN 
2061 Cornell Road, Suite 301B 
Cleveland, OH 44106 
Phone: (216) 844-3259 
Fax: (216) 844-5523 
E-Mail: walton.trisha@clevelandactu.org  
 
Pharmacist 
 
Michael Banchy, RPh 
11100 Euclid Ave #122, Suite B-52 
Cleveland, OH 44106 
Phone: (216) 844-8018 
Fax: (216) 844-1445 
E-Mail: Michael.banchy@uhhospitals.org 
 
Statistician 
 
Curtis Tatsuoka, PhD 
Departments of Neurology and Epidemiology 
and Biostatistics 
Case Western Reserve University 
2103 Cornell Road, Suite 6206 
Cleveland, OH 44106 
Phone:  (216) 368-6724 
Fax: (216) 368-4835 
E- Mail: cmt66@case.edu 
 
Laboratory Coordinator 
 
Daniela Moisi 
2109 Adelbert Road, Suite 1048B 
Cleveland, OH 44106 
Phone: (216) 368-4853 
Fax: (216) 368-5415 
E-Mail: Moisi.Daniela@clevelandactu.org 
Regulatory Coordinator 
 
Cheryl Smith 
2061 Cornell Road, Suite 303 
Cleveland, OH 44106 
Phone: (216) 844-8052 
Fax: (216) 844-5523 
E-Mail: smith.cheryl@clevelandactu.org  
 


 
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DAIDS Medical Officer 
 
Randall L. Tressler, MD 
5601 Fishers Lane 
Rm 9E47 
Rockville, MD 20852 
Phone:  (917) 547-7279 
E-Mail: randall.tressler@nih.gov 
 
Unit Administrator 
 
Mary Robertson 
2061 Cornell Road, Suite 401 
Cleveland, OH 44106 
Phone: (216) 844-2342 
Fax: (216) 844-5523 
E-Mail: robertson.mary@clevelandactu.org  
 
 


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


 
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GLOSSARY OF ABBREVIATIONS 
 
AE 
Adverse event 
AIDS 
Acquired immunodeficiency syndrome 
ALT 
 
Alanine aminotransferase 
ANC 
 
Absolute neutrophil count 
Apo  
 
Apolipoprotein 
ART 
 
Antiretroviral therapy 
ARV 
 
Antiretroviral 
AST 
 
Aspartate aminotransferase 
AUC 
 
Area under the curve 
BART  
Brachial arterial reactivity testing 
BUN 
 
Blood urea nitrogen 
CBC 
 
Complete blood count 
CDC 
(United States) Centers for Disease Control and Prevention 
CFR 
 
Code of Federal Regulations 
CFSE  
Carboxyfluorescein succinimidyl ester 
CLIA   
Clinical Laboratory Improvement Amendments  
Cmax 
 
Maximum serum concentration 
CRF 
Case report form 
CRP 
C-reactive protein 
CV 
Cardiovascular 
CVD 
Cardiovascular disease 
DAIDS 
Division of AIDS 
DCRU 
Dahms Clinical Research Unit 
DMARD 
Disease-modifying antirheumatic drug 
DMPA  
Depot medroxyprogesterone acetate 
DNA 
 
Deoxyribonucleic acid 
EAE 
 
Expedited adverse event 
ELISA  
Enzyme-linked immunosorbent assay 
FDA 
 
(United States) Food and Drug Administration 
FMD 
 
Flow-mediated dilatation 
GALT  
Gut-associated lymphoid tissue 
GCP 
 
Good Clinical Practices 
GFR 
Glomerular filtration rate 
GC-MS  
Gas chromatography–mass spectrometry 
HANC  
HIV/AIDS Network Coordination 
HBcAb 
Hepatitis B core antibody 
HBcAg 
Hepatitis B core antigen 
HBeAg 
Hepatitis B e antigen 
HBsAb 
Hepatitis B surface antibody 
HBsAg 
Hepatitis B surface antigen 
HBV 
Hepatitis B virus 
HCV 
Hepatitis C virus 
HDL 
High-density lipoprotein 
HIV 
Human immunodeficiency virus 
HOMA-IR 
Homeostatic model assessment of insulin resistance 
IATA 
International Air Transport Association  


 
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IFABP  
Intestinal fatty acid binding protein  
IGRA 
Interferon-gamma release assay 
IL 
Interleukin 
IND 
 
Investigational new drug  
IoR 
 
Investigator of Record  
IRB 
Institutional review board 
IUD 
 
Intrauterine device 
IV 
 
Intravenous 
LC-MS  
Liquid chromatography–mass spectrometry 
LDL 
Low-density lipoprotein 
Lp(a)   
Lipoprotein(a) 
LPS 
Lipopolysaccharide 
MOPS 
Manual of operating procedures 
mTOR  
Mammalian target of rapamycin 
NIAID 
(United States) National Institute of Allergy and Infectious Diseases 
NIH 
 
(United States) National Institutes of Health 
NNRTI  
Non-nucleoside reverse transcriptase inhibitor 
NRTI  
Nucleoside reverse transcriptase inhibitor 
OHRP  
Office for Human Research Protections 
OxLDL  
Oxidized LDL  
PBMC 
Peripheral blood mononuclear cells  
PD 
 
Pharmacodynamic(s) 
PD-1 
Programmed cell death protein 1 
PK 
Pharmacokinetic(s) 
PON-1  
Paraoxonase/arylesterase 1 
PRN 
 
As needed 
PRO 
 
Protocol Registration Office 
PT 
 
Prothrombin time 
PTID  
Participant identification number 
PTT 
 
Partial thromboplastin time 
RPR 
 
Rapid plasma reagin 
RA 
Rheumatoid arthritis 
RNA 
Ribonucleic acid 
SAE 
Serious adverse event 
sCD14   
Soluble CD14 
sCD163  
Soluble CD163  
sCD40L   
Soluble CD40 ligand 
SIU 
Special Immunology Unit  
SMC 
Safety monitoring committee 
SUSAR 
Suspected and unexpected serious adverse reactions 
sVCAM   
Soluble vascular adhesion molecule 
TCZ 
Tocilizumab 
TNF 
 
Tumor necrosis factor 
TNFr 
Tumor necrosis factor receptor  
UA 
 
Urinalysis  
UHCMC 
University Hospitals Case Medical Center 
ULN 
 
Upper limit of normal 
USPI  
U. S. Prescribing Information 


 
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VLDL 
Very low-density lipoprotein 
VTI  
 
Hyperemic velocity time integral 
 
 
 


 
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AIDS347: IL-6 Blockade in Treated HIV Infection 
 
 
INVESTIGATOR SIGNATURE FORM 
 
 
FINAL Version 4.0 
12 March 2015 
 
Funded by: 
Division of AIDS, US National Institute of Allergy and Infectious Diseases 
US National Institutes of Health 
 
IND Holder and Sponsor:  
Benigno Rodriguez, MD 
 
I, the Investigator of Record, agree to conduct this study in full accordance with the 
provisions of this protocol.  I will comply with all requirements regarding the obligations of 
investigators as outlined in the Statement of Investigator (Form FDA 1572), which I have also 
signed.  I agree to maintain all study documentation for at least two years following the date of 
marketing approval for the study product for the indication in which it was studied.  If no 
marketing application is filed, or if the application is not approved, the records will be retained 
for two years after the investigation is discontinued, the US Food and Drug Administration is 
notified, and the site’s final Financial Status Report is filed with the National Institutes of Health 
(NIH).  
 
I have read and understand the information in the U.S. Prescribing Information (USPI) 
including the potential risks and side effects of the products under investigation, and will ensure 
that all associates, colleagues, and employees assisting in the conduct of the study are 
informed about the obligations incurred by their contribution to the study. 
 
 
____________________________ 
Name of Investigator of Record 
 
 
____________________________ 
______________________________ 
Signature of Investigator of Record  
Date 
 
 
 
 
 


 
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SCHEMA 
 
DESIGN 
The study is a phase I/II, double-blind, placebo-controlled, randomized cross-
over clinical trial of tocilizumab (TCZ) or placebo in HIV-infected subjects 
receiving antiretroviral therapy with suppressed viral replication and CD4+ T 
cell count ≥350 and ≤1,000 cells/mm3) 
 
DURATION 
48 weeks (40 weeks during cross-over treatment periods) total per subject. 
 
SAMPLE 
SIZE 
30 subjects with complete data up to week 30. Up to 36 subjects may be 
enrolled in order to achieve an estimated final sample size of 30 participants 
with complete data up to week 30. 
 
POPULATION HIV-infected male and female subjects from 18 through 60 years of age 
receiving combination antiretroviral therapy (ART) without changes in the 24 
weeks prior to enrollment (changes for reasons other than virologic failure 
allowed up to 8 weeks prior to enrollment), with suppressed plasma HIV RNA 
(<200 copies/mL, one blip up to <1,000 copies/mL permitted) for at least 96 
weeks and a CD4+ T-cell count ≥350 and ≤1,000 cells/mm3 at the time of 
study enrollment. 
 
REGIMEN 
Subjects will be randomized 1:1 to one of the following arms:  
ARM A:  TCZ, 4 mg/Kg by IV infusion over 60 minutes (not to exceed 400 mg) 
once at study entry, followed by TCZ, 8 mg/Kg by IV infusion over 60 
minutes (not to exceed 800 mg) at weeks 4 and 8, and THEN 
placebo by IV infusion at weeks 20, 24, and 28. 
ARM B: Placebo by IV infusion at study entry followed by placebo by IV 
infusion at weeks 4 and 8, and THEN TCZ, 4 mg/Kg (not to exceed 
400 mg) by IV infusion over 60 minutes once at week 20, followed by 
TCZ, 8 mg/Kg (not to exceed 800 mg) by IV infusion over 60 minutes 
at weeks 24 and 28. 
 
  
 
Figure 1. Study schema for the on-treatment period. Triangles indicate the dates of study agent administration. Empty symbols = 4 
mg/Kg dose; solid symbols = 8 mg/Kg dose. 
End of
study
40
4
8
24
28
30
0
Study
entry
Arm A
Arm B
Placebo
TCZ
Arm
switch
20
Placebo
TCZ
Washout
period
Period 1
Period 2
Primary
endpoint
Primary
endpoint
10
Post-treatment
Follow-up


 
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1.0 HYPOTHESES AND STUDY OBJECTIVES 
 
1.1 Hypotheses 
 
 
We hypothesize that TCZ, a humanized monoclonal antibody against the IL-6 receptor, 
at a dose of 4 mg/Kg once followed by two doses of 8 mg/Kg every four weeks 
beginning 4 weeks after the first dose, will be safe and well tolerated among HIV-
infected subjects receiving suppressive antiretroviral therapy.  
 
Additionally, we hypothesize that TCZ will reduce systemic inflammation, reduce 
abnormal central memory CD4 T cell cycling, and restore systemic and gut immune cell 
responsiveness to IL-7 through enhancement of CD127 expression.  
 
We further hypothesize that TCZ will improve the cardiometabolic risk profile (as 
reflected by improved brachial artery endothelial function, decreased procoagulant 
indices, and/or diminished serum levels of inflammatory and atherogenic).  
 
Finally, we hypothesize that TCZ will promote a transcriptomic and metabolomic profile 
that more closely resembles that seen in patients who have achieved robust CD4 T cell 
count reconstitution after suppressive antiretroviral therapy, with downregulation of the 
interferon and inflammatory pathways that we have previously described are commonly 
upregulated among patients with blunted CD4+ T cell count reconstitution. 
 
1.2 Primary Objectives 
 
1.2.1  To assess the safety and tolerability of tocilizumab, at a dose of 4 mg/Kg once 
followed by two monthly doses of 8 mg/Kg beginning 4 weeks after the first dose, 
among HIV-infected subjects fully suppressed on stable antiretroviral therapy 
with a plasma HIV RNA below 200 copies/mL and a CD4 T cell count ≥350 and 
≤1,000 cells/mm3.  
 
1.2.2. To determine if the mean serum C-reactive protein (CRP, a marker of 
inflammation) level two weeks after the last dose of study agent (weeks 10 and 
30) is significantly lower within subjects after TCZ than after placebo, in a mixed-
effects model that includes CRP level at the beginning of each study period 
(study entry and week 20). 
 
1.2.3  To determine if the proportion of central memory CD4 T cells expressing the 
nuclear antigen Ki67 (a reflection of cell cycling) two weeks after the last dose of 
study agent (weeks 10 and 30) is significantly lower within subjects after TCZ 
than after placebo, in a mixed-effects model that includes CD4 T cell cycling at 
the beginning of each study period (study entry and week 20).  
 
1.3 Secondary Objectives 
 
 
1.3.1 To determine if TCZ, at the doses described above, will enhance expression of 
the IL-7 receptor α chain CD127 on peripheral blood and gut CD4 T cells from  


 
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the beginning of each study period (study entry and week 20) to 2 weeks after 
the last dose in each period of the trial (weeks 10 and 30, respectively). 
 
1.3.2 To establish whether TCZ administration will reduce serum CRP and central 
memory cycling from the beginning of each study period (study entry and week 
20) to any post-TCZ administration time point. 
 
1.3.3 To determine if TCZ administration will enhance CD127 expression on peripheral 
CD4 T cells, as well as on rectal CD4 T cells among those subjects who choose 
to provide rectal biopsy specimens, from the beginning of each study period 
(study entry and week 20)  to any post-TCZ administration time point.  
 
1.3.4 To assess whether TCZ will increase bcl-2 expression and/or decrease annexin 
V binding by Ki67+ T cells from the beginning of each study period (study entry 
and week 20)  to 2 weeks after the last dose in each period of the trial (weeks 10 
and 30, respectively). 
 
1.3.5 To assess whether TCZ will enhance ex vivo responsiveness to IL-7, as reflected 
by Stat 5 phosphorylation and α4β7 expression, and in vivo responsiveness to 
IL-7 as reflected by spontaneous expression of α4β7 by peripheral CD4 T cells 
from the beginning of each study period (study entry and week 20) to 2 weeks 
after the last dose in each period of the trial (weeks 10 and 30, respectively). 
 
1.3.6  To establish whether TCZ will result in decreased CD4 T cell activation, as 
manifested by CD38/HLA-DR coexpression from the beginning of each study 
period (study entry and week 20)  to 2 weeks after the last dose in each period of 
the trial (weeks 10 and 30, respectively). 
 
1.3.7  To determine whether TCZ will reduce plasma levels of IL-7, and whether 
circulating IL-7 level changes correlate with CD127 expression on CD4 T cells at 
each timepoint and from the beginning of each study period (study entry and 
week 20)  to 2 weeks after the last dose in each period of the trial (weeks 10 and 
30, respectively). 
 
 
1.3.8 To assess whether TCZ will increase CD4 T cell density in the gut associated 
lymphoid tissue (GALT), and GALT lymphocyte expression of IL-17, and IL-22 
from baseline to 2 weeks after the last dose in each period of the trial (weeks 10 
and 30). 
 
 
1.3.9 To determine whether TCZ will replenish numbers and function of innate 
lymphoid cells (ILC) and cells expressing retinoid-related orphan receptor 
gamma from the beginning of each study period (study entry and week 20) to 2 
weeks after the last dose in each period of the trial (weeks 10 and 30, 
respectively).   
 
1.3.10  To establish whether TCZ will increase expression of mucosal barrier genes 
(occludins and claudins) by rectosigmoid epithelial cells from baseline to 2 weeks 
after the last dose in each period of the trial (weeks 10 and 30). 
 


 
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1.3.11  To assess whether TCZ will reduce the extent of mucosal breach and 
inflammatory infiltration of the distal colonic submucosa from study entry to 2 
weeks after the last dose in each period of the trial (weeks 10 and 30). 
 
 
1.3.12 To determine whether TCZ will decrease other plasma biomarkers of gut barrier 
integrity, microbial translocation, inflammation and coagulation, including 
lipopolysaccharide (LPS), soluble CD14 (sCD14), tumor necrosis factor receptors 
I and II (TNFrI and TNFrII), D-dimers, and intestinal fatty acid binding protein 
(IFABP), and increase levels of the plasma marker of intestinal barrier integrity 
zonulin from the beginning of each study period (study entry and week 20) to 2 
weeks after the last dose in each period of the trial (weeks 10 and 30, 
respectively).  
 
1.3.13 To study whether TCZ will lead to improved endothelial function, as reflected by 
the change in flow-mediated dilatation and hyperemic velocity time integral from 
baseline to 2 weeks after the last dose in each period of the trial (weeks 10 and 
30), and whether changes in endothelial function indices will correlate with 
soluble markers of inflammation and microbial translocation at those time points.  
 
1.3.14 To assess whether TCZ will reduce tissue factor expression on patrolling and 
inflammatory monocytes from the beginning of each study period (study entry 
and week 20) to 2 weeks after the last dose in each period of the trial (weeks 10 
and 30, respectively).  
 
1.3.15 To establish whether TCZ will reduce levels of selected cardiovascular risk 
markers, including soluble vascular adhesion molecule (sVCAM), soluble CD40 
ligand (sCD40L), soluble CD163 (sCD163), P-selectin (CD62P), and E-selectin 
from the beginning of each study period (study entry and week 20) to 2 weeks 
after the last dose in each period of the trial (weeks 10 and 30, respectively). 
 
 
1.3.16 To explore the effects of TCZ on systemic levels of inflammatory and atherogenic 
lipids and on lipoprotein profile, including HDL, LDL, and VLDL cholesterol, 
apolipoproteins A1 and B (ApoA1 and ApoB), pro-inflammatory HDL, 
paraoxonase/arylesterase 1 (PON-1), oxidized LDL, and lipoprotein(a) (Lp(a)) 
from the beginning of each study period (study entry and week 20) to 2 weeks 
after the last dose in each period of the trial (weeks 10 and 30, respectively). 
 
 
1.3.17 To assess whether TCZ will improve indices of insulin resistance, as reflected by 
changes in homeostatic model assessment of insulin resistance (HOMA-IR) from 
the beginning of each study period (study entry and week 20) to 2 weeks after 
the last dose in each period of the trial (weeks 10 and 30, respectively). 
 
 
1.3.18 To determine whether TCZ administration is associated with changes in systemic 
levels of the adipokines adiponectin, leptin, and resistin from the beginning of 
each study period (study entry and week 20) to 2 weeks after the last dose in 
each period of the trial (weeks 10 and 30, respectively). 
 
 


 
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1.3.19 To define the transcriptomic profile of naïve and central memory CD4 T cells and 
monocyte subsets associated with IL-6 blockade by TCZ, and to correlate it with 
the plasma metabolomic profile in HIV-infected subjects during antiretroviral-
induced suppression of viral replication.  
 
 
1.3.20 To describe the safety profile of short-term administration of TCZ in HIV-infected 
subjects receiving a stable antiretroviral regimen with suppressed viral replication 
and a CD4 T cell count ≥350 and ≤1,000 cells/mm3.  
 
1.3.21 To explore the effect of TCZ administration on trough levels of antiretrovirals, 
particularly protease inhibitors, in HIV-infected subjects receiving a stable 
antiretroviral regimen with suppressed viral replication and a CD4 T cell count 
≥350 and ≤1,000 cells/mm3. 
 
2.0 INTRODUCTION 
 
2.1 Background and Rationale for Blocking IL-6 as a Therapeutic Strategy in Immune 
Failure 
 
2.1.1 Immune Failure and Immune Success with Antiretroviral Therapy 
 
In the current treatment era, successful control of HIV replication typically 
promotes CD4 T cell restoration but a substantial minority of successfully treated 
subjects fails to increase CD4 T cell counts to levels that are within the normal 
range among HIV-uninfected persons. This phenomenon, which we have termed 
“immune failure”, is linked to a greater risk of morbid complications (1-5), but its 
mechanisms are not well understood.  We have established a cohort of immune 
failure subjects (the Cleveland Immune Failure –CLIF–  cohort) who, despite at 
least 2 years of virologic control, failed to increase circulating CD4 T cell counts 
to at least 350 cells/mm3 (6). In this group, there were profound decreases in all 
circulating CD4 T cell maturation subsets, as well as decreases in naïve CD8 T 
cells, implicating a failure of T cell homeostasis. Importantly, immune failure 
patients showed an elevated frequency of cycling CD4 central memory T cells 
but normal CD8 T cycling, despite persistent CD4 and CD8 T cell activation 
(CD38/HLA-DR coexpression) (6). Inflammatory (IL-6) and coagulation indices 
(D-dimers) were elevated as was monocyte activation, with increased levels of 
the soluble LPS receptor sCD14. While LPS levels tended to be higher in 
immune failures than in immune successes and healthy controls (21, 18 and 12 
pg/mL respectively) these differences did not reach statistical significance (6). 
Thus, persons with immune failure on virologically suppressive antiretroviral 
therapy also have evidence of immune activation, inflammation and heightened 
coagulation.  
 
2.1.2  Role of Immune Activation/Inflammation and Coagulation in HIV Disease. 
 
There is increasing evidence that immune activation and inflammation are central 
to the pathogenesis of HIV-1-related disease. Suppressive antiretroviral 
therapies 
typically 
attenuate 
these 
phenomena, 
but 
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activation/inflammation is often demonstrable in treated HIV-1 infection despite 
virologic control, especially among immune failures (6, 7). The drivers and 
determinants of activation and inflammation in this setting are not fully 
characterized. Yet, a growing body of data link activation/inflammation and 
coagulation to the morbidity of HIV-1 infection in the treatment era, as is also the 
case with other systemic inflammatory diseases.  
 
In an analysis including both arms of the Strategic Management of Antiretroviral 
Therapy (SMART) trial, a large prospective, randomized trial comparing ART 
administration guided by CD4 count versus sustained virologic suppression(8), 
higher plasma levels of the cytokine interleukin-6, of C-reactive protein and D-
dimers independently predicted morbidity and mortality (9).   
 
2.1.3  Inflammatory Markers also Predict Mortality in Treated HIV-1 Infection.  
 
In a recent study, higher plasma levels of inflammatory markers, markers of 
coagulation and of intestinal permeability were associated with mortality in a 
case-control study performed in two San Francisco cohorts (SOCA and SCOPE) 
(10). All participants had achieved virologic control with therapy and cases and 
controls were matched for CD4 T cell counts at treatment initiation. In these 
studies, being in the highest quartile of IL-6 levels was associated with an odds 
ratio for mortality of over 100-fold relative to subjects in the lowest quartile. 
Indices of gut mucosal barrier breach (high intestinal fatty acid binding protein 
and low zonulin) were also associated with mortality, while cellular markers of 
activation (coexpression of CD38 and HLA-DR), senescence (CD57, CD28-) or 
naïve cell numbers were not (10).  
 
These results have been recently confirmed and expanded in a case control 
study of 450 HIV infected persons who initiated antiretroviral therapy and 
controlled viremia in the AIDS Clinical Trials Group ALLRT cohort (NWCS 329). 
In this study, before initiation of antiretroviral therapy, one year after treatment 
start and in the most recent sampling before the occurrence of a major morbid 
event (non-accidental death, MI, stroke, malignancy and major bacterial 
infection), inflammatory (IL-6, IP-10, sTFNr1, sTNFrII, sCD14), and coagulation 
(D-dimers) markers were significantly associated with increased odds ratios for 
these events. As in the study including SOCA and SCOPE participants cited 
above, IL-6 level was the most robust correlate of morbidity and mortality, and 
cellular activation markers did not predict outcome except for expression of 
programmed cell death protein 1 (PD-1) on CD4 T cells.  
 
Thus, an inflammation profile, especially higher IL-6 levels, reproducibly predicts 
morbidity and mortality in treated HIV infection despite virologic control, and  
persons who maintain low CD4 T cell numbers are at greater risk for these 
events (1-5). Not surprisingly, these markers of inflammation and coagulation are 
strongly correlated with each other. While understanding cellular pathways of 
activation and inflammation may provide hints about the causal meaning of these 
associations (e.g., IL-6 can drive CRP(11) and TNF can drive IL-6 (12)), the 
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signals in vivo may render these relationships even more complex than might be 
anticipated on the basis of pathway analyses in individual cell populations.  Thus, 
an informative way to explore the relationships among these markers is to 
examine the response to an intervention that targets a plausible mediator and 
clinically correlated activity marker. In this study, we plan to explore the effects of 
IL-6, one of the two biomarkers consistently correlated with increased morbidity 
and mortality, by inhibiting IL-6 activity using TCZ. This will allow us to explore 
the effect the IL-6 pathway has on these inflammatory, activation and coagulation 
markers to determine the role of IL-6 in their regulation and interactions.  
 
2.1.4  Interleukin-6 and its Potential Role in Immune Failure 
 
IL-6 is a cytokine produced by multiple cell types, including T cells, B cells, 
monocyte/macrophages, and fibroblasts that exerts its biologic activity by binding 
to its cellular receptors CD126 and CD130. Soluble CD130 can bind IL-6 and 
inhibit its biologic activity, while IL-6 bound to soluble CD126 can interact with 
cellular CD130 inducing both JAK/STAT3 dependent and ERK 1 /2 MAP kinase 
activation. IL-6 induces acute phase reactant (e.g. CRP) expression in the liver 
and can act as an endogenous pyrogen. IL-6 has been implicated in 
demargination of circulating neutrophils and induction of adhesion molecules 
VCAM and ICAM-1 on endothelial cells (13, 14). First described as B cell 
stimulatory molecule, IL-6 promotes antibody production by promoting maturation 
of T follicular helper cells (15). IL-6 also is reported to increase mitogen-induced 
CD4 T cell proliferation, and this has been attributed to blockade of IL-2 
production and Treg induction (16). In murine studies, IL-6 has been linked to 
induction of a TH2 response and inhibition of IL-12-induced Th1 responses (17). 
Together with TGFB, IL-6 may direct naïve T cells to acquire a TH17 phenotype 
(18). Thus, IL-6 exhibits both pro-inflammatory and anti-inflammatory features, 
and may be implicated in the maintenance of an accelerated, and perhaps 
maladaptive, state of T cell proliferation in response to a variety of stimuli.   
 
While numerous mechanisms including virus-induced cell death likely contribute 
to CD4 T cell deficiency in untreated HIV infection, the determinants of persistent 
CD4 lymphopenia (immune failure) in treated HIV infection are incompletely 
understood but likely include both increased cellular death and a failure to 
sustain cellular production/maturation. It has been shown (19-21) that turnover of 
central memory CD4 T cells is an important feature of the immune deficiency in 
HIV infection and in the SIV model, the ultimate loss of these cells predicts 
mortality (22). While increased cycling of both CD4 and CD8 memory cells is 
readily demonstrable in untreated HIV infection (20, 23), immune failures with 
controlled HIV replication have both sustained high plasma levels of IL-6 and 
increased cycling and turnover of central memory CD4 T cells, while CD8 T cell 
cycling is normal (6). We have found that central memory CD4 T cell cycling and 
death can be induced in vitro by exposure to microbial TLR ligands (24). This 
appears to be mediated largely by the induction of IL-6, as the cycling of memory 
CD4 T cells induced by LPS is inhibited in the presence of the IL-6 receptor 
inhibitor TCZ  and IL-6 alone is sufficient to induce cycling of central memory 
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characteristic of immune failure in the presence of virologic control (6). We 
therefore propose that elevated systemic levels of IL-6 are important drivers of 
central memory CD4 T cell cycling and turnover in immune failure.  
 
2.1.5  IL-6 May Block Cellular Restoration in Immune Failure by Decreasing Expression 
of the IL-7 Receptor α Chain (CD127).  
 
Failure of CD4 T cell restoration in HIV infection has been linked to impaired 
thymic production (25, 26) and to increased lymphoid tissue fibrosis (27, 28). 
More recent work has suggested that collagen deposition in the fibroblastic 
reticular cell network in these nodes may block T cell access to the homeostatic 
cytokine IL-7 (29). IL-7 drives T cell proliferation and supports T cell survival by 
inducing expression of anti-apoptotic bcl-2 (30, 31). In HIV infection, diminished T 
cell expression of CD127, the IL-7 receptor α chain, may also limit the 
effectiveness of whatever IL-7 levels are available (32, 33). And while diminished 
CD127 expression has been linked to both immune failure and to immune 
activation in HIV infection (34, 35), the mechanisms whereby this might take 
place are not at all understood (36, 37).  
 
In vitro, IL-6 exposure decreases the expression of CD127 on both CD4 and CD8 
T cells, and that decrease in CD127 expression induced by LPS exposure is 
reversed by TCZ(38). We therefore hypothesize that sustained systemic 
exposure to IL-6 decreases T cell expression of CD127 in vivo and contributes to 
HIV associated immune failure.  
 
2.1.6  HIV Replication does not Appear to Be a Major Determinant of IL-6 Expression 
and IL-6 Levels in Plasma Remain Elevated despite ARV-induced Control of HIV 
Replication.  
 
Although several studies have demonstrated weak but significant relationships 
between HIV and IL-6 levels in plasma of untreated patients (39, 40), this 
relationship disappears within the first weeks of ARV therapy (41) and IL-6 levels 
in plasma remain elevated in effectively treated HIV infection (6, 41).  In vitro, 
neither productive infection with HIV nor exposure to HIV could induce IL-6 
expression by PBMC, macrophages, lymph node histocultures or colonic 
mucosal explants. Moreover, lymph node histocultures prepared from HIV 
infected subjects actually expressed less IL-6 spontaneously than did lymph 
node histocultures prepared from control subjects (41). Unlike exposure to HIV, 
exposure of lymphoid tissue to microbial products such as LPS and flagellin 
results in robust IL-6 induction. 
 
2.1.7  The Gut May Be a Major Source of the Elevated IL-6 Levels in Treated HIV 
Infection.  
 
Substantially elevated levels of IL-6 mRNA levels have been found in colonic 
biopsies of HIV-infected subjects when compared to levels among uninfected 
controls and were unrelated to the magnitude of plasma viremia (42, 43). We 
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systemic levels of IL-6 that characterize treated and untreated HIV infection. In 
this model, HIV infection and elimination of gut mucosal CD4 T cells during the 
first few weeks of infection (44) result in diminished expression of the T helper 
cytokines IL-22 and IL-17, which are necessary to maintain an intact gut 
epithelium (45). The resultant breakdown in the gut epithelial tight junction 
permits greater transition of luminal microbial products into the mucosal lamina 
propria that then induce greater monocyte expression of pro-inflammatory 
cytokines, including upregulation of IL-6 expression. Exposure to increased IL-6 
levels decreases CD127 expression on other mucosal T cells and ILC resulting in 
their death and/or failure to express IL-17 and IL-22, with attendant further 
breach of the intestinal barrier. A relationship between systemic translocation of 
microbial products and systemic IL-6 levels is also supported by our observation 
in a previous study (6) of a significant correlation between plasma IL-6 levels and 
plasma levels of bacterial lipopolysaccharide (r = 0.287 ; P = 0.009)(41). Yet, 
these relationships do not establish causality. The observations below suggest 
that such a causal relationship is plausible. 
 
2.1.8  Increased Gut Mucosal Expression of IL-6 in HIV Infection May Be both Cause 
and Consequence of Microbial Translocation.  
 
There is increasing evidence that gut mucosal defenses are dependent upon the 
interplay among mucosal defense cells, the mucosal epithelium, which comprises 
a key barrier to intraluminal retention of microbial elements, and the expression 
of mucosal defense cytokines such as IL-22, IL-23 and IL-17 (45). Mucosal 
defense cells include T cells, dendritic cells of several distinct lineages, natural 
killer cells, B lymphocytes, and a group of innate lymphoid cells (ILC) that lack 
lineage markers but are important sources of IL-22. These cells can be induced 
to express IL-22 by exposure to IL-23 (46) and IL-22 expressed by mucosal 
defense cells is a key inducer of the T helper cytokine IL-17, which is an 
important regulator of gut mucosal integrity (47). ILC are identifiable in human 
and mouse gut mucosae. In murine systems, their depletion permits systemic 
dissemination of a gram negative bacterium, Alcaligenes sp, that is at least 
partially corrected after systemic administration of IL-22 (46). Thus, ILC and their 
IL-22 product appear to play an important role in compartmentalization and 
containment of a gut luminal microbe.  
 
In rhesus macaques, colonic mucosal CD4 and CD8 T cells express both IL-22 
and IL-17 and in SIV infection, the frequencies of IL-22 producing and IL-17 
producing T cells are diminished dramatically (48). In SIV infected rhesus, 
extensive LPS infiltration can be demonstrated by immunostaining (49), and this 
has substantial consequences for gut integrity as in SIV infected rhesus, the 
frequencies of IL-22 producing CD4 and CD8 T cells in colonic tissues and 
mesenteric lymph nodes correlate indirectly with an index of intestinal barrier 
breach (the ratio of claudin positive to claudin negative sites) (48). In acute SIV 
and HIV infection, depletion of CD4+ IL-22 producing cells is attributable to viral 
infection and cell death, yet this does not explain the CD8+ T cell defects or the 
frequent failure of gut CD4 T cell restoration after antiretroviral therapy (50) and 
the persistence of systemic microbial translocation despite virologic control (51).  


 
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2.1.9 Expression of the IL-7 Receptor Alpha Chain (CD127) May Be Necessary to 
Maintain the Frequency and Survival of Gut T Cells and ILC that Sustain Mucosal 
Integrity and Barrier Function.   
 
IL-7 promotes T cell expansion and survival (52) and, when administered 
exogenously to HIV-infected persons with immune failure, induces dramatic 
expansion of circulating CD4 and CD8+ T cells (30, 31) without induction of a T 
regulatory phenotype such as is seen after systemic IL-2 administration (53). IL-7 
may also play a critical role in maintaining gut mucosal integrity as both in vitro 
and in vivo IL-7 upregulates T cell expression of the α4β7 integrin, which 
promotes lymphocyte homing to gut mucosal sites (54, 55). By inducing 
expression of bcl2, IL-7 also promotes T cell survival and resistance to pro-
apoptotic signals. This effect may not be restricted to an effect on T cells as ILC 
also express high levels of CD127 (46) and these cells are thought to be critically 
dependent upon IL-7 for survival (45). We hypothesize that IL-7 plays an 
important role in gut mucosal barrier integrity by both inducing expression of the 
gut homing receptor α4β7 and promoting survival of the gut mucosal T cells and 
ICL that are key sources of IL-22. Preliminary results from our group suggest that 
this could be the case as systemic IL-7 administration both increases CD4 T cell 
restoration in the gut and decreases systemic levels of sCD14 and D-dimers, 
known predictors of morbidity and mortality in treated HIV infection (55). We 
hypothesize that microbe-induced expression of IL-6 renders gut mucosal T cells 
and ILC less responsive to IL-7 dependent survival signals that perpetuates 
breach in the gut epithelial barrier, and anticipate that blockade of IL-6 action by 
TCZ will reverse this cycle, increasing mucosal T cell and ILC CD127 expression, 
promoting their survival, increasing IL-22 and IL-17 expression, and restoring gut 
barrier function with resulting attenuation of microbial translocation and further 
inflammation.   
 
2.1.10 Cardiovascular Risk in Treated HIV Infection, the Role of Inflammation and IL-6   
 
In the current HIV treatment era, a major cause of morbidity and mortality is 
cardiovascular disease (CVD) (56). There is mounting evidence that CVD risk is 
increased in HIV infection despite virologic suppression and while “traditional” 
risk factors for cardiovascular events are important drivers of this risk, it is likely 
that the systemic inflammation that characterizes even treated HIV infection 
contributes to this risk as it does in a number of inflammatory rheumatologic 
conditions (57). A number of observations suggest that IL-6 may play a causal 
role in increased CVD risk. High plasma levels of IL-6 are associated with 
subsequent risk of myocardial infarction in the general population, and a 
systematic review of 17 large population-based prospective studies of IL-6 found 
a strong association between long-term average IL-6 levels  and clinical coronary 
outcomes (MI or coronary death) (58). As shown in our preliminary data above, 
increased IL-6 levels predict overall morbidity and mortality, including 
cardiovascular morbidity and mortality in HIV infection. There is genetic evidence 
to support a role for IL-6 in coronary artery disease risk as a single nucleotide 
polymorphism in the IL-6 receptor gene that results in a non-synonymous 
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and a clinical profile compatible with IL-6 receptor blockade in the general 
population (59, 60). Moreover, Mendelian analysis strongly suggested that the 
association is causal, rather than correlative (60). Finally, there is evidence that 
IL-6 blockade results in improved endothelial function, as reflected by flow-
mediated dilatation after 6 months of treatment with TCZ in RA patients (61).    
 
 
2.1.11 Other Proposed Interventions to Manage Inflammation in HIV Infection 
 
Whereas a highly targeted approach such as the one proposed in this study is 
valuable in providing a narrowly focused intervention that allows for a greater 
understanding of the role of a critical inflammatory mediator in HIV pathogenesis, 
more broadly acting agents have also been proposed. Thus, the non-absorbable 
polymer sevelamer (ClinicalTrials.gov Identifier NCT01543958) and the non-
absorbable antibiotic rifaximin (ClinicalTrials.gov Identifier NCT01866826) have 
been studied as options to block absorption and production of intestinal microbial 
products, respectively. The toll-like receptor (TLR) signaling inhibitor chloroquine 
has been shown to reduce cellular immune activation modestly in chronic HIV 
infection (62), and the antimetabolite methotrexate is now being studied as an 
anti-inflammatory in HIV-infected persons as well (ClinicalTrials.gov Identifier 
NCT00000834). Rosuvastatin has been shown to decrease markers of monocyte 
activation and the vascular inflammation marker Lp-PLA2 in treated HIV-infected 
subjects (63). Other proposed applications of statins in HIV infection take the 
opposite approach, and instead of using these agents as broadly anti-
inflammatory interventions, they are being used as modulators of risk with the 
specific goal of reducing the occurrence of comorbid endpoints such as 
cardiovascular 
disease 
(ClinicalTrials.gov 
Identifier 
NCT00965185) 
and 
neurocognitive impairment (ClinicalTrials.gov Identifier NCT01263938). The 
angiotensin receptor inhibitor telmisartan has been shown to reduce visceral 
adiposity in HIV infection(64), but its effects on inflammation appear inconclusive 
and might include paradoxical increases in monocyte activation (65).   
 
Thus, the intervention proposed in this study complements other proposed 
approaches, targets one of inflammatory biomarkers most consistently correlated 
with morbidity and mortality in HIV infected individual, modulates inflammation 
and immune activation in HIV infection, and is distinct from other planned 
strategies. In addition, it isolates a single step in the inflammatory cascade, 
thereby representing a unique opportunity to understand the contribution of IL-6 
to the global state of heightened inflammation in treated HIV infection.  
 
2.2 Rationale  
 
2.2.1 Rationale for the Choice of Study Agent 
 
As outlined above, IL-6 may play a role not only as a reflection of systemic 
inflammation and immune activation in treated HIV infection, but as a true 
mediator of pathogenesis, particularly in the setting of incomplete immune 
reconstitution. Blocking the biological activity of IL-6 in vivo would potentially 
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the pathogenesis cascade in treated HIV infection and exploring whether TCZ 
can reduce markers of inflammation, coagulation and immune activation that 
have been associated with increased risk of morbidity and mortality.  
 
Tocilizumab (TCZ) is a humanized monoclonal antibody that binds and 
neutralizes both soluble and membrane bound IL-6 receptors and is a potent 
anti-inflammatory.  It has been approved by the FDA for the treatment of: 
 
• 
Adult patients with moderately to severely active rheumatoid arthritis (RA) 
who have had an inadequate response to one or more disease-modifying 
anti-rheumatic drugs (DMARD) 
• 
Patients 2 years of age and older with active polyarticular juvenile idiopathic 
arthritis (PJIA) 
• 
Patients 2 years of age and older with active systemic juvenile idiopathic 
arthritis (SJIA). 
 
In Japan, TCZ has also been approved for treatment of Castleman’s disease.  
 
The onset of action and clinical benefits of TCZ in RA are rapid, with dramatic 
reductions of inflammatory markers observed by day 14 after starting therapy 
(66). Clinical signs and symptoms also may respond early and continue to 
improve over the first 12-24 weeks. CRP levels fall dramatically and rapidly after 
TCZ administration, as do other inflammatory markers. In a small pilot study of 
patients with rheumatoid arthritis, TCZ administration was associated with 
improvements in endothelial function, as assessed by flow-mediated dilatation 
(61). Thus, TCZ appears to be a potent blocker of IL-6 activity with easily 
demonstrable systemic anti-inflammatory activity. While the macrolide rapamycin 
has been shown to inhibit lymphocyte proliferation in response to IL-2, IL-4, and 
IL-6, it does so by binding to and inhibiting the downstream effects of the protein 
kinase mammalian target of rapamycin (mTOR), a regulator of protein translation 
essential to the control of the cell cycle; it likely has little effect on events 
proximal to IL-6. Moreover, the lack of specificity of rapamycin makes it difficult to 
attribute any observed effects to IL-6 inhibition alone.  
 
2.2.2 Safety of TCZ 
 
An overview of known adverse events associated with TCZ administration is 
provided below. Details of the TCZ risk mitigation strategy are provided in section 
12.6.1. 
 
Risks associated with the use of TCZ include infections, some leading to 
hospitalization or death, hypersensitivity reactions including anaphylaxis, 
gastrointestinal (GI) perforations, infusion reactions, laboratory abnormalities 
(neutropenia, thrombocytopenia, AST and ALT elevations, elevations of lipids) 
and malignancies.  In the five Phase III clinical trials the most common AEs (>5% 
of patients) treated with 8 mg/kg TCZ monotherapy through 6 months of therapy 
were upper respiratory tract infection, nasopharyngitis, headache, hypertension 
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biologic therapies and cases of herpes zoster exacerbation were observed in 
clinical studies with TCZ.  
 
2.2.2.1 Serious Infections 
 
Serious infections leading to hospitalization or death due to bacterial, 
mycobacterial, invasive fungal, viral, protozoal or other opportunistic 
pathogens, have occurred in patients receiving immunosuppressive 
agents including TCZ for RA. In the 24-week, controlled clinical studies, 
the rate of serious infections in the TCZ monotherapy group was 3.6/100 
patient-years compared to 1.5 per 100 patient-years in the methotrexate 
group. The rate of serious infections in the 4 mg per kg and 8 mg per kg 
TCZ plus DMARD group was 4.4 and 5.3 events per 100 patient-years, 
respectively, compared to 3.9 events per 100 patient-years in the placebo 
plus DMARD group. The most common serious infections included 
pneumonia, urinary tract infection, cellulitis, herpes zoster, gastroenteritis, 
diverticulitis, sepsis and bacterial arthritis. Cases of opportunistic 
infections have been reported. Patients presented with disseminated 
rather than localized disease, and were often taking concomitant 
immunosuppressants such as methotrexate or corticosteroids which in 
addition to rheumatoid arthritis may have predisposed them to infections. 
 
To mitigate the risk of serious infections, patients with a recent history or 
current active infections will be excluded, and patients with concomitant 
conditions or indications for medications that can contribute to further 
immunosuppression will also be excluded. Details of the risk mitigation 
strategy for serious infections can be found in section 12.6.1.1. 
 
2.2.2.2 Hypersensitivity Reactions 
 
Hypersensitivity reactions, including anaphylaxis and death, have been 
reported in association with infusion of TCZ. Clinically significant 
hypersensitivity reactions, including anaphylaxis associated with TCZ and 
requiring treatment discontinuation were reported in 0.1% (3/2644) in the 
24-week, controlled trials and in 0.2% (8/4009) in the all-exposure 
population.  
 
Appropriate medical treatment will be available for immediate use in the 
event of a serious hypersensitivity reaction, and all the doses will be given 
on an inpatient basis. Details of the risk mitigation strategy for 
hypersensitivity reactions can be found in section 12.6.1.2.  
 
2.2.2.3 Gastrointestinal Perforations 
 
Gastrointestinal perforations, mostly colonic, have been reported in 
patients receiving TCZ.  During the 24-week, controlled clinical trials, the 
overall rate of gastrointestinal perforation was 0.26 events/100 patient-
years with TCZ therapy.  In the all-exposure population, the overall rate of 


 
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gastrointestinal perforation remained consistent with rates in the 
controlled periods of the studies. Reports of gastrointestinal perforation 
were primarily reported as complications of diverticulitis including 
generalized purulent peritonitis, lower gastrointestinal perforation, fistula 
and abscess. Most patients who developed gastrointestinal perforations 
were taking concomitant nonsteroidal anti-inflammatory medications 
(NSAIDs), corticosteroids, or methotrexate. The relative contribution of 
these concomitant medications versus TCZ to the development of 
gastrointestinal perforations is not known. 
 
To mitigate the risk of GI perforations, patients at risk for these 
complications will be excluded, concomitant immunosuppressive agents 
will be prohibited, and abdominal symptoms will be promptly evaluated to 
identify possible cases of perforation as early as possible. Details of the 
risk mitigation strategy for gastrointestinal perforation can be found in 
section 12.6.1.3. 
 
2.2.2.4 Infusion Reactions 
 
Adverse events associated with the infusion (occurring during or within 24 
hours of the start of infusion) were reported in 8% and 7% of patients in 
the 4 mg/kg and 8 mg/kg TCZ plus DMARD groups, respectively, 
compared to 5% of patients in the placebo plus DMARD group in the 24 
week, controlled clinical studies. The most frequently reported event 
during the infusion was hypertension (1% for both the 4 and 8 mg/kg 
doses), while the most frequently reported events occurring within 24 
hours of finishing an infusion were headache (1% for both doses) and 
skin reactions (1% for both doses), including rash, pruritus and urticaria. 
There was no difference in infusion reactions between the 4 and 8 mg/kg 
doses, and they were not treatment limiting. 
 
To reduce the risk of severe infusion reactions, subjects will be closely 
monitored during and after infusion (for which they will be admitted as 
inpatients to the Dahms Clinical Research Unit) with frequent vital sign 
monitoring, and immediate availability of qualified medical treatment and 
resuscitation medications and equipment. Details of the risk mitigation 
strategy for infusion reactions can be found in section 12.6.1.4. 
 
2.2.2.5 Laboratory Abnormalities 
 
 
2.2.2.5.1 Neutropenia   
 
In the 24 week, controlled clinical studies, neutropenia, defined 
as decreases in absolute neutrophil counts (ANC) to below 
1,000 cells/mm3, occurred in 1.8% and 3.4% of patients in the 4 
mg per kg and 8 mg per kg TCZ plus DMARD group, 
respectively, compared to 0.1% of patients in the placebo plus 
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below 1,000 cells/mm3 occurred within 8 weeks of starting 
therapy. Decreases in neutrophil counts to below 500 cells/mm3 
occurred in 0.4% and 0.3% of patients in the 4 mg/kg and 8 
mg/kg TCZ plus DMARD group, respectively, compared to 0.1% 
of patients in the placebo plus DMARD group. There was no 
clear relationship between decreases in neutrophils to below 
1,000/mm3 and the occurrence of serious infections. In the all-
exposure population, the pattern and incidence of decreases in 
neutrophil counts remained consistent with what was seen in the 
24-week controlled clinical studies. 
 
To reduce the risk of neutropenia, subjects with an ANC below 
2,000 cells/mm3 will be excluded, and study treatment will be 
temporarily or permanently discontinued if the ANC falls during 
the study to between 500 and 1,000 cells/mm3 or below 500 
cells/mm3, respectively, as recommended in the USPI. Details of 
the risk mitigation strategy for neutropenia can be found in 
section 12.6.1.5.1.   
 
 
2.2.2.5.2 Thrombocytopenia 
 
In the 24 week, controlled clinical studies, decreases in platelet 
counts below 100,000/mm3 occurred in 1.3% and 1.7% of 
patients on 4 mg/kg and 8 mg/kg TCZ plus DMARD, 
respectively, compared to 0.5% of patients on placebo plus 
DMARD, without associated bleeding events.  In the all-
exposure population, the pattern and incidence of decreases in 
platelet counts remained consistent with what was seen in the 
24 week controlled clinical studies. 
 
To reduce the risk of thrombocytopenia, subjects with a platelet 
count below 100,000/mm3 will be excluded, and study treatment 
will be temporarily or permanently discontinued if the platelet 
count falls during the study to between 50,000 and 100,000/mm3 
or below 50,000/mm3, respectively, as recommended in the 
USPI. Details of the risk mitigation strategy for neutropenia can 
be found in section 12.6.1.5.2. 
 
 
2.2.2.5.3 Liver Enzyme Elevations 
 
Treatment with TCZ was associated with a higher incidence of 
transaminase 
elevations 
than 
placebo. 
Liver 
enzyme 
abnormalities in the 24-week controlled period of registrational 
studies are summarized in table 1. In patients experiencing liver 
enzyme elevation, modification of treatment regimen, such as 
reduction in the dose of concomitant DMARD, interruption of 
TCZ, or reduction in TCZ dose, resulted in decrease or 
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associated with clinically relevant increases in direct bilirubin, 
nor were they associated with clinical evidence of hepatitis or 
hepatic insufficiency. In the all-exposure population, the 
elevations in ALT and AST remained consistent with what was 
seen in the 24 week, controlled clinical trials. 
 
Table 1. Incidence of liver enzyme abnormalities in the 24 week controlled period of studies 
  
  
TCZ 8 mg/Kg 
Methotrexate 
TCZ 4 mg/Kg 
TCZ 8 mg/Kg 
Placebo 
  
  
MONOTHERAPY 
  
+ DMARDs 
+ DMARDs 
+ DMARDs 
  
  
N = 288 
N = 284 
N = 774 
N = 1582 
N = 1170 
  
  
(%) 
(%) 
(%) 
(%) 
(%) 
AST (U/L) 
  
  
  
  
  
> ULN to 3x ULN 
22 
26 
34 
41 
17 
> 3x ULN to 5x ULN 
0.3 
2 
1 
2 
0.3 
  
> 5x ULN 
0.7 
0.4 
0.1 
0.2 
< 0.1 
ALT (U/L) 
  
  
  
  
  
> ULN to 3x ULN 
36 
33 
45 
48 
23 
> 3x ULN to 5x ULN 
1 
4 
5 
5 
1 
  
> 5x ULN 
0.7 
1 
1.3 
1.5 
0.3 
 
To reduce the risk of liver enzyme abnormalities, subjects with 
underlying serious liver disease will be excluded, as will subjects 
with an AST or ALT >1.5 times the upper limit of normal (ULN). 
The dose of study treatment will be reduced for AST or ALT 
values persistently greater than 1.4 xULN but below 3xULN, and 
study treatment will be temporarily or permanently discontinued 
if AST or ALT values are persistently 3xULN to 5xULN or above 
5xULN, as recommended in the USPI. Details of the risk 
mitigation strategy for liver enzyme abnormalities can be found 
in section 12.6.1.5.3. 
 
 
2.2.2.5.4 Lipid Elevations  
 
Total cholesterol, LDL cholesterol, HDL cholesterol, and 
triglycerides were first assessed at 6 weeks following initiation of 
TCZ in the controlled 24 week clinical trials. Increases were 
observed at this time point and remained stable thereafter. 
Increases in triglycerides to levels above 500 mg per deciliter 
were rarely observed. Mean changes in other lipid parameters 
from baseline to week 24 in the 8 mg/kg TCZ monotherapy arm 
are summarized below: 
 
• Mean LDL cholesterol increased by 25 mg per dL 
• Mean HDL cholesterol increased by 4 mg per dL  
• Mean LDL/HDL cholesterol ratio increased by 0.26 
• ApoB/ApoA1 ratios were essentially unchanged. 
In the all-exposure population, the elevations in lipid parameters 
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controlled clinical trials. Elevated lipids responded to lipid 
lowering agents. 
 
There was no increase in myocardial infarctions associated with 
TCZ use in the integrated TCZ safety data base (control group 
0.49/100 PY, 0.18/100PY TCZ 4 mg/kg, 0.17/100PY TCZ 8 
mg/kg) (67), and although lipids increased with TCZ therapy, 
CRP levels and insulin resistance were dramatically reduced 
and arterial flow mediated dilatation was increased (68).  The 
net effect of TCZ on CVD risk is unknown, but is unlikely to be 
affected by 8 weeks of therapy.  No specific risk mitigation steps 
have been implemented for lipid perturbations seen with TCZ. 
 
2.2.2.6 Malignancies 
 
Malignancies were diagnosed in 15 patients receiving TCZ, compared to 
8 malignancies in patients in the control groups during the 24-week, 
controlled period of the registrational studies. Exposure-adjusted 
incidence was similar in the TCZ groups (1.32 events/100 patient-years) 
and in the placebo plus DMARD group (1.37/100 patient-years). In the all-
exposure population, the rate of malignancies remained consistent with 
the rate observed in the 24 week, controlled period. The impact of TCZ on 
malignancies is unknown. 
 
To minimize the risk or emergent or recurrent malignancies, subjects with 
a history of or active cancer will be excluded. Details of the risk mitigation 
strategy for malignancies can be found in section 12.6.1.6. 
 
2.2.2.7 Viral Reactivation 
 
Herpes zoster exacerbations, or shingles, have been reported in patients 
receiving TCZ(69). About one in ten adults who have experienced wild 
type varicella-zoster viral infection will have shingles when the virus 
reemerges during a period of stress. The seroprevalence of varicella-
zoster virus antibodies among adults ages 20-49 in the United States, 
which presumably represents a group of individuals infected with varicella 
zoster prior to the approval of the varicella live virus vaccine in 1995, 
exceeds 95%(70), suggesting that excluding individuals with a history of 
chicken pox or a positive antibody titer would make the study infeasible. 
Consistent with the USPI, a history of or a positive antibody titer to herpes 
zoster will therefore not be exclusionary for this study.  
 
Reactivation of hepatitis B has occurred in patients previously exposed to 
hepatitis B virus (HBV) receiving DMARDs, most commonly tumor 
necrosis factor (TNF) inhibitors. The risk of HBV reactivation after 
administration of TCZ is unknown, but may be lower than that associated 
with TNF inhibitors(71), as the most recent post-marketing report from 
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patients treated with TCZ despite the high background prevalence of HBV 
infection in that country (Genentech, data on file). More specifically with 
regards to patients with serological evidence of previous HBV exposure, a 
recent study reported outcomes among 8 RA patients with positive 
hepatitis B core antibody (HbcAb), but negative HbsAg and HBV DNA 
below the limit of quantitation at the beginning of treatment with TCZ. 
None of these patients received prophylactic antivirals, and none 
experienced HBV reactivation after 18 months of follow-up(72). In another 
study that included 17 RA patients who were either HbcAb- or HbsAb-
positive and had HBV DNA below the limit of quantitation at the start of 
TCZ treatment, two patients had a detectable HBV during a median of 18 
months of follow-up, but HBV levels never increased beyond the 
quantitation limit of the assay (2.1 log10 copies/mL), were not associated 
with liver enzyme elevation or clinical symptoms, and reverted to 
undetectable spontaneously without antiviral treatment(73). In a third 
study including 157 HbsAg-negative, HbcAb- or HbsAb-positive RA 
patients who received treatment with any of six biological DMARDs, 
including TCZ, 13 patients developed a detectable HBV DNA during 18 
months of follow-up, one of them while receiving TCZ(74). HBV DNA 
positivity in the patient receiving TCZ resolved spontaneously within a 
month, and none of the 13 patients who developed reactivation had 
concomitant liver enzyme abnormalities, although ten of them received 
treatment with entecavir(74). TCZ has also been used safely in two 
patients with RA and one patient with adult-onset Still’s disease and 
preexisting chronic active hepatitis B(75-77). Importantly, almost all 
reported cases of HBV reactivation during DMARD treatment have 
involved patients receiving other immunosuppressive agents together 
with DMARDs. 
 
Expert opinion(78) and guidelines from the American Association for the 
Study of Liver Diseases(79), the American Society of Clinical 
Oncology(80), the European Association for the Study of the Liver(81), 
the US National Institutes of Health(82), and the US Centers for Disease 
Control and Prevention(83), all coincide in recommending, with various 
degrees of certainty, screening using a combination of HbsAg, HbcAb, 
and HBV DNA at the beginning of various immunsuppressive therapies. 
The role of active antiviral prophylaxis, on the other hand, is unclear 
except in the setting of profoundly immunosupressive chemotherapy and 
is likely to be most beneficial among patients with evidence of ongoing 
HBV replication (e.g., positive HbsAg, HBV DNA, or HbeAg). In this study, 
subjects with positive HbsAg, HBV DNA, or HbeAg will be excluded, and 
those with evidence of resolved HBV infection (i.e., positive HbcAb) will 
be required to be receiving an HIV antiretroviral regimen that includes at 
least one agent with anti-HBV activity, such as lamivudine, emtricitabine, 
or tenofovir. Details of other features of the protocol that might mitigate 
the risk of viral reactivation can be found in section 12.6.1.7.  
 


 
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2.2.2.8 Cytochrome P450 Inhibition and Decreased Plasma Levels of 
Antiretrovirals  
 
Inhibition of IL-6 signaling in RA patients treated with TCZ may restore 
CYP450 activities to higher levels than those in the absence of TCZ, 
leading to increased metabolism of drugs that are CYP450 substrates. In 
vitro studies showed that TCZ has the potential to affect expression of 
multiple CYP enzymes including CYP1A2, CYP2B6, CYP2C9, CYP2C19, 
CYP2D6 and CYP3A4. Its effects on CYP2C8 or transporters are 
unknown. In vivo studies with omeprazole, metabolized by CYP2C19 and 
CYP3A4, and simvastatin, metabolized by CYP3A4, showed up to a 28% 
and 57% decrease in exposure one week following a single dose of TCZ, 
respectively.  
 
The effects of TCZ on individual ARV levels are unknown, but based on 
the data, they can be assumed to represent a restoration to exposure 
levels that are comparable to those in patients with lower levels of 
inflammation, e.g., those with immune reconstitution success. Thus, even 
if TCZ administration results in relatively diminished exposure to 
antiretrovirals metabolized by CYP3A4, it is not expected to reach levels 
where therapeutic efficacy would be compromised.   
 
Nonetheless, to mitigate the risk of reduced levels of antiretroviral 
medications, subjects receiving non-boosted protease inhibitors will be 
excluded, and trough levels of protease inhibitors and non-nucleoside 
reverse transcriptase inhibitors will be monitored throughout the study. 
Details of the risk mitigation strategy for reduced levels of antiretrovirals 
can be found in section 12.6.1.8.  
 
2.2.2.9 Demyelinating Disorders 
 
The impact of TCZ on demyelinating disorders is not known, but multiple 
sclerosis and chronic inflammatory demyelinating polyneuropathy have 
been reported rarely in clinical studies.  
 
To minimize the risk of emerging demyelinating disorders, subjects with a 
history of such conditions will be excluded, and all subjects will be 
monitored closely at each visit for signs or symptoms indicative of a 
demyelinating disease. Details of the risk minimization strategy for 
demyelinating disorders can be found in section 12.6.1.9. 
 
 
2.2.2.10 Immunogenicity 
 
In the 24-week, controlled clinical studies, a total of 2,876 patients have 
been tested for anti-TCZ antibodies. Forty-six patients (2%) developed 
positive anti-TCZ antibodies, of whom 5 (0.17%) had an associated, 
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Thirty patients (1%) developed neutralizing antibodies. The data reflect 
the percentage of patients whose test results were positive for antibodies 
to TCZ in specific assays. No specific risk mitigation interventions are 
planned to mitigate the risk of TCZ immunogenicity. 
 
2.2.2.11 Safety of TCZ in HIV-infected Individuals 
 
Limited data are available about the safety and tolerability of TCZ in HIV-
infected patients. TCZ is approved for treatment of multicentric 
Castleman’s disease in Japan, where it has been used successfully to 
treat both HHV-8-positive and HHV-8-negative cases (84), but few cases 
with HIV infection have been reported. At least one HIV-infected patient 
has been treated in Europea, and it is likely that a number of other 
patients with HIV infection have been treated in Japan, although the 
experience has not been published in the peer-reviewed literature.  
 
A National Cancer Institute (NCI)-sponsored open-label, pilot clinical trial 
of TCZ for treatment of Castleman’s disease in HIV-infected and HIV-
uninfected patients is now underway in the US (ClinicalTrials.gov 
identifier: NCT01441063). As of April 18, 2013, 3 HIV-positive subjects 
had been enrolledb. All subjects were well controlled on ritonavir-boosted 
protease inhibitor-containing regimens, and their CD4+ T cell counts at 
entry were 203, 323, and 421 cells/mm3. All patients received 8 mg/Kg of 
TCZ every 2 weeks for 8 doses total. All three patients have completed 
the course of study medication, although one of the patients did not 
receive all the scheduled doses because progression of the Castleman’s 
disease was documented during follow-up (in total, 17 doses were 
administered among 3 subjects). None of the patients had dose-limiting 
toxicities. One patient experienced a mild infusion reaction consisting of 
grade 2 pruritus, which resolved with symptomatic treatment, and 
tolerated subsequent doses with the use of a low-dose antihistamine. 
There were several transient episodes of mild cytopenias, which were 
attributed by the investigators to the concomitant use of zidovudine and 
valganciclovir. Subjects maintained control of HIV replication during 
exposure to TCZ. There have been no infectious complications. 
 
 
2.2.3  Rationale for Rectosigmoid Biopsies 
 
The gastrointestinal tract and in particular the gut-associated lymphoid tissue 
have long been recognized as a major site of HIV replication beginning at the 
earliest stages of HIV infection, regardless of the route of infection. More 
recently, the gastrointestinal tract has also emerged as one of the most active 
sites of HIV pathogenesis, both as a rich source of HIV-susceptible cellular 
targets, and as the potential source, through impaired integrity of the barrier 
                                                          
a Personal communication  1 May 2013, Mark Bower, Department of Oncology, Chelsea and Westminster   
Hospital, London, UK 
b Personal communication, 18 April 2013, Thomas Uldrick National Cancer Institute, Bethesda, MD 


 
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function of the intestinal epithelium, for entry of microbial-derived products into 
the systemic circulation, which in turn likely contribute to the heightened state of 
cell cycling and immune activation that is characteristic of progressive HIV 
infection.  
 
IL-6 mRNA expression levels in colonic biopsy specimens are elevated in HIV 
infection (42), and we propose that IL-6 might, through both direct and indirect 
mechanisms, contribute to enhanced microbial translocation from the intestinal 
lumen and to disruption of the mucosal barrier function integrity even after 
suppression of systemic HIV replication by antiretroviral therapy (see sections 
2.1.7 through 2.1.9). Therefore, this study will provide an invaluable opportunity 
to test these hypotheses and to improve our understanding of the role of IL-6 in 
the causal cascade leading to impaired CD4 T cell reconstitution in treated HIV 
infection. While only a subset of participants is expected to participate in the 
rectosigmoid biopsy collection part of this study, the insights gained even from a 
small number of subjects before and after the administration of TCZ will greatly 
enhance the contribution of this study to the field of HIV immunopathogenesis.  
 
2.2.3.1 Risks of Rectosigmoid Biopsy 
  
Risks associated with lower gastrointestinal endoscopy include colitis 
from chemicals for endoscope sterilization, bowel perforation, bleeding, 
diverticulitis, and infection. The frequency of serious complications after 
flexible sigmoidoscopy is extremely low. In two large studies (85, 86) 
including a combined 144,832 clinically indicated procedures, the 
incidence of serious complications ranged from 0.06 to 0.8%. Obtaining 
biopsies may be associated with an increased risk of complications. The 
best available data on the risk of multiple biopsies comes from studies of 
dysplasia surveillance among patients with long-standing inflammatory 
bowel disease, in whom large numbers of “blind” biopsies are obtained 
throughout the colon for early detection of malignant transformation. In 
two such studies (87, 88) including a combined 3,011 procedures and a 
median of eight (88) and 17 biopsies (87), respectively, there was only 
one serious complication, for an incidence of approximately 0.33%.  
 
More relevant to the present protocol, in a study of subjects undergoing 
endoscopic procedures exclusively for research purposes (89), including 
64 sigmoidoscopies with a mean of 25 biopsies obtained from the 
rectosigmoid, there were no major complications. Thirteen subjects 
experienced minor symptoms (self-limited bleeding and pain), which were 
not related to the number of biopsies. Thus, the risk of serious 
complications from the proposed study procedures, even with up to 20 
biopsy specimens, is expected to be very low.  
 
To minimize the risks of flexible sigmoidoscopy with biopsies, subjects 
with conditions or exposure to medications that might increase the risk of 
complications from these procedures will be excluded, and procedures 
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protocols of the University Hospitals Case Medical Center Digestive 
Health Institute. Details on the risk mitigation strategy for the flexible 
sigmoidoscopy procedure can be found in section 12.6.3.  
 
2.2.4  Rationale for Study Population 
 
As outlined above, we have an extensive body of preliminary data in HIV-infected 
individuals to suggest that heightened immune activation is not only a constant 
feature of immune failure on successful antiretroviral therapy, but also a strong 
predictor of adverse outcomes in this clinical scenario. Moreover, we have shown 
that IL-6 likely plays a role in both impairing CD4 T cell reconstitution and in 
mediating some of the forms of increased morbidity and mortality observed in 
these patients, including cardiovascular disease. Therefore, HIV-infected 
individuals who are suppressed on ART, but who continue to have elevated IL-6 
levels may be most likely to benefit from an intervention aimed at interrupting a 
critical step in the inflammatory process. The long duration of virologic 
suppression required for enrollment will ensure that subjects are receiving a well-
tolerated and effective antiretroviral regimen and that they have reached steady-
state levels of immune activation and inflammation secondary to effective ART. 
Requiring a CD4 cell count ≥350 cells/mm3 will reduce the risk of opportunistic 
complications.  
 
The determination of a threshold to segregate patients who experience 
“immunologic failure” and those who experience “immunologic success” is a 
source of considerable controversy. In our previous study (6), we used a 
threshold of 350 cells/mm3 to define immunologic failure, based on the lower limit 
of normal CD4 T cell count at our institution and on the threshold for initiation of 
antiretroviral treatment at the time of that work.  
 
More recently, however, we have examined subjects in our previously published 
experience who have less pronounced blunting of CD4 T cell reconstitution, in 
the range that will be included in this study. In that segment of the population, 
those with CD4 T cell counts between 500 and 1,000 cells/µL, we found that 
levels of soluble plasma markers of inflammation and coagulation, including IL-6, 
the monocyte activation marker soluble CD14, and the intravascular coagulation 
marker D-dimer remain elevated to levels that are distinguishable from those 
seen among HIV-uninfected healthy controls (figure 2). Therefore, we feel 
confident that even after excluding patients with extremely blunted CD4 T cell 
reconstitution (below 350 cells/µL), who might have an elevated residual risk of 
opportunistic complications, we will still be able to target a population with 
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2.2.5 
Rationale for Inclusion of Women of Reproductive Potential 
 
Given that globally more than 50% of HIV-infected individuals are women, and 
that both men and women are at increased risk of morbidity and mortality 
associated with chronic immune activation and inflammation seen in HIV-infected 
individuals who are virologically suppressed on ART, it is important to include 
women in the interventional clinical trials. Further, inclusion of women of 
reproductive potential might be important, if it can be done safely, to assess the 
potential impact of sex hormones on the intervention. 
 
 
TCZ has been approved by the FDA for the treatment of RA in adult men and 
women with an inadequate response to other approved therapies and for the 
treatment of active SJIA and/ active PJIA in pediatric patients > 2 years of age.  It 
is a Pregnancy Category C compound, indicating that there are no adequate and 
well-controlled studies in pregnant women. In pregnant cynomolgus monkeys 
treated during organogenesis, at doses IV at up to 6.25 times the levels used in 
this study, there was no evidence of teratogenic or dysmophogenic effect.  
However, there was an increased incidence of abortion/embryo-fetal death. In 
mice, an analogue of TCZ, dosed at 50 mg/kg IV three times per week, from 
implantation through 21 days after delivery, showed no evidence for any 
functional impairment of the development and behavior, learning ability, immune 
competence and fertility of the offspring.  Based on these data, the USPI states 
that TCZ should be used during pregnancy only if the potential benefit justifies 
the potential risk to the fetus. It is also not known whether tocilizumab is excreted 
in human milk or absorbed systemically after ingestion. Therefore, because there 
is no proven benefit of TCZ to treat chronic inflammation and immune activation 
in HIV+ individuals suppressed on ART, pregnant and breastfeeding women will 
be excluded from this study.   
 
For women of reproductive potential, multiple safeguards to minimize the risk of 
unintended exposure to TCZ during pregnancy have been incorporated into the 
Figure 2. Plasma levels of IL-6, sCD14, and D-dimers among HIV-infected patients with suppressed plasma 
viremia for at least 2 years and CD4+ T cell counts between 500 and 1,000 cells/µL, compared to healthy, 
HIV-uninfected controls. One extreme outlying value is not shown. 
 
IL-6, pg/mL
HIV-neg
control
CD4 500-1,000
cells/µL
3
2
1
0
Soulble CD14, ng/mL
3,000
2,000
1,000
0
HIV-neg
control
CD4 500-1,000
cells/µL
D-Dimers, ng/mL
600
500
400
300
200
100
0
HIV-neg
control
CD4 500-1,000
cells/µL


 
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study, including required negative pregnancy tests before each dose of study 
treatment, requirement of two valid methods of contraception verified before each 
study treatment dose, and careful monitoring of FDA updates regarding safety of 
the study agent in this population. Details about the risk mitigation strategy for 
women of reproductive potential can be found in section 12.6.1.10.  
 
2.2.6 Rationale for a Crossover Design 
 
A crossover design increases efficiency and reduces sample size requirements 
by reducing inter-subject variability, since each subject is his/her own control. 
 
The condition treated here, immune activation and inflammation, fulfills generally 
accepted criteria for a crossover design, as it is a chronic state that cannot be 
expected to be permanently eliminated by the therapeutic intervention. Because 
of the gain in efficiency, we will be able to conduct the trial while exposing as 
small a group of subjects as possible to the study agent in this exploratory, 
pathogenesis-driven trial.  
 
The intervention, TCZ administration, has a rapid onset of action and a limited 
duration after discontinuation of treatment, as shown by the return of erythrocyte 
sedimentation rate and C-reactive protein to baseline values within 4 to 8 weeks 
after the last infusion of TCZ to RA patients (90). Thus, we have built in a 
prolonged washout period of 12 weeks that should provide sufficient protection 
against a carryover effect. The terminal half-life of TCZ is 151 ± 59 hours, 
indicating that the proposed washout period is adequate to ensure minimal 
residual concentrations of TCZ. We will monitor serum TCZ levels by ELISA to 
confirm that this is the case. The information collected will also be of interest to 
understand potential differences in pharmacokinetics and pharmacodynamics of 
TCZ in HIV-infected persons receiving antiretroviral therapy.  
 
2.2.7 Rationale for Duration of Study 
 
We sought to identify the minimum exposure necessary to ensure that a 
biological effect could be observed while minimizing exposure risks and sample 
size. In RA trials (91), a plateau in clinical benefit appears to be reached around 
month 3 of treatment, and PK modeling suggests that a steady-state is reached 
after approximately 8 weeks of treatment with the 8 mg/Kg dose (92). Thus, we 
will administer the full 8 mg/Kg dose for 2 months, the minimum interval we 
expect to offer a good probability of observing the peak biological activity. 
According to the USPI, we will initiate treatment with the lower dose of 4 mg/Kg.  
 
3.0 STUDY DESIGN 
 
This is a phase I/II, double-blind, crossover trial of TCZ, 4 mg/Kg IV followed 4 weeks 
later by TCZ, 8 mg/Kg IV every 4 weeks for 2 doses, or matching placebo, in male and 
female HIV-infected subjects between 18 and 60 years of age receiving combination 
antiretroviral therapy without changes due to virologic failure (i.e., confirmed detectable 
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(<200 copies/mL) for at least 96 weeks and a CD4 T-cell count ≥350 and ≤1,000 
cells/mm3 at the time of study enrollment. Subjects will be assigned randomly to one of 
the following sequences: TCZ as described above followed by a 12 week washout 
period and then matching placebo administered in an identical schedule, or vice versa.  
 
All subjects will be offered the option to undergo rectal mucosal biopsy via flexible 
sigmoidoscopy at baseline, week 10, and week 30, but participation in the rectal tissue 
collection procedures will not be necessary in order to be enrolled in the study. Flexible 
sigmoidoscopies will be performed on the dates of regularly scheduled visits that all 
study participants, regardless of involvement in the rectal specimen collection part, will 
be asked to complete. Subjects who choose to participate in the rectal specimen 
collection part of the study will have to meet all the same inclusion and exclusion criteria 
as those who choose not to participate, with the difference that a few additional 
precautions and prohibited medications and conditions apply to subjects in the rectal 
sampling section of the study (section 4.2.17).   
 
4.0 SELECTION AND ENROLLMENT OF SUBJECTS 
 
4.1 Inclusion Criteria 
 
4.1.1 Men and women age 18-60 years. 
 
4.1.2 Ability and willingness to communicate in English or Spanish 
 
4.1.3 Ability and willingness of subject to provide informed consent. 
 
4.1.4 Ability and willingness to provide adequate locator information. 
 
4.1.5 HIV-1 infection, documented by any licensed rapid HIV test or HIV enzyme or 
chemiluminescence immunoassay (E/CIA) test at any time before study entry 
and confirmed by a licensed Western blot, a second antibody test by a method 
other than rapid HIV or E/CIA; HIV-1 antigen; or plasma HIV-1 RNA viral load. 
 
4.1.6 Receiving a stable antiretroviral regimen consisting of 3 or more drugs belonging 
to two or more classes, one of which must be a protease inhibitor, an integrase 
inhibitor, or a non-nucleoside reverse transcriptase inhibitor, without any changes 
due to virologic failure in the past 24 weeks, and with no plans to change 
antiretroviral regimen in the 40 weeks following enrollment. If the regimen 
includes a protease inhibitor, ritonavir or an approved boosting agent known to 
increase trough levels of the protease inhibitor by at least 50% must also be a 
part of the regimen.  
 
NOTE A: 
Changes to the antiretroviral regimen 8 weeks or more prior to 
enrollment are allowed if the plasma HIV RNA was <50 copies/mL 
at the time of the change, the reason for the change was not 
suspicion or documentation of virologic failure, and all other 
criteria for virologic control, as outlined in criterion 4.1.9 below, are 
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NOTE B: 
For the purposes of this protocol, “a change due to virologic 
failure” is defined as any of the following events or combinations 
thereof happening in a patient who is receiving uninterrupted 
combination antiretroviral therapy including at least three agents 
belonging to at least two classes: a) plasma HIV RNA is >200 
copies/mL on two or more consecutive occasions; b) the treating 
physician determines that any given plasma HIV RNA value is 
indicative or suggestive of virologic failure, and recommends that 
the patient’s regimen be modified as a result; c) a genotypic or 
phenotypic antiretroviral resistance test identifies the presence of 
resistance to any component of a patient’s regimen that was not 
present before, and a physician recommends that the patient’s 
regimen be modified as a result.  
 
4.1.7 For subjects who have a positive HBcAb only:  
 
• 
An antiretroviral regimen containing one or more of the following 
medications: lamivudine, emtricitabine, or tenofovir.  
 
 
4.1.8 Screening CD4+ T-cell count ≥350 cells/mm3 but ≤1,000 cells/mm3 performed in 
a laboratory that has a Clinical Laboratory Improvement Amendments (CLIA) 
certification or its equivalent. 
 
4.1.9 HIV-1 RNA <200 copies/mL at every time a plasma HIV RNA has been obtained, 
but no fewer than twice, in the 96 weeks prior to enrollment.  
 
NOTE:  One plasma HIV RNA above 200 copies/mL but lower than 1,000 copies 
in the 96 weeks prior to enrollment is permissible if flanked by two 
measurements that are both below 200 copies. The HIV-1 RNA at 
screening must be <50 copies/mL. 
 
4.1.10 The following laboratory values obtained within 60 days prior to entry: 
• Hgb ≥10 g/dL 
• Platelet count >100,000/mm3 
• Absolute neutrophil count (ANC) ≥2,000 cells/mm3 
• Aspartate aminotransferase (AST) [serum glutamic oxaloacetic transaminase 
(SGOT)] <1.5x ULN 
• Alanine aminotransferase (ALT) [serum glutamic pyruvic transaminase 
(SGPT)] <1.5x ULN 
• For subjects who consent to undergo rectal tissue sampling only: 
International normalized ratio (INR) < 1.7 
• Total bilirubin <3.0 mg/dL, EXCEPT for subjects receiving atazanavir 
• For subjects receiving atazanavir: Direct bilirubin ≤1.0 mg/dL 
• Calculated GFR ≥60 mL/min/1.73m2   
 
4.1.11 Female subjects of reproductive potential must have a negative serum or urine 
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pregnant for the duration of the study.  
 
NOTE: For the purposes of this protocol, a female subject of reproductive 
potential is defined as one who has reached menarche, has not been 
post-menopausal for at least 24 consecutive months (i.e., has had 
menses within the preceding 24 months), and has not undergone surgical 
sterilization (e.g., hysterectomy, tubal ligation, or bilateral oophorectomy).  
 
4.1.12 Female subjects of reproductive potential participating in sexual activity that 
could lead to pregnancy must agree to use at least one of the following forms of 
birth control for at least 30 days prior to study entry through 30 days after the 
final study visit: 
 
• 
Condoms (male or female) with or without a spermicidal agent  
• 
Diaphragm or cervical cap with spermicide 
 
 
PLUS at least one of the following:  
  
• 
An FDA-approved copper intrauterine device (IUD), e.g. ParaGard®, or an 
FDA-approved hormone-releasing IUD, e.g. Mirena® 
• 
An FDA-approved transdermal hormonal contraceptive, e.g. Ortho-Evra® 
• 
An FDA-approved injectable hormonal contraceptive, e.g. Depo-Provera® 
• 
An FDA-approved hormonal contraceptive in vaginal ring form, e.g. 
NuvaRing®  
• 
An FDA-approved implantable hormonal contraceptive, e.g. Implanon® or 
Jadelle® 
 
NOTE A:  Oral hormonal contraceptives, either combined or progestin-only, are 
not acceptable as a second contraceptive method. 
 
NOTE B: 
Women of reproductive potential who are using a hormonal 
contraceptive not included above may consider switching their 
contraceptive to one of the approved forms, but will be required to do 
so in consultation with their primary healthcare providers. Study 
investigators will not prescribe or recommend a specific form of 
contraception to study participants. The study will not cover the costs 
of contraceptives.  
 
4.1.13 Female subjects who are not of reproductive potential [i.e., women who have 
been post-menopausal for at least 24 consecutive months or women who have 
undergone surgical sterilization (e.g., hysterectomy, tubal ligation, or bilateral 
oophorectomy)] are eligible without requiring the use of a contraceptive. 
Acceptable documentation of sterilization, other contraception methods, 
menopause and reproductive potential is patient-reported history at any time 
prior to screening.   
 
4.1.14 Subjects must be determined by the investigators to have at least one fully active 
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entry. The determination of whether or not an alternative regimen is available 
must take into account both the subject’s antiretroviral history and any previously 
obtained resistance testing. A valid alternative regimen must meet the 
recommendations for an active regimen outlined in the current DHHS guidelines 
for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents 
(93).     
 
4.2 Exclusion Criteria 
 
4.2.1 History of one of the following opportunistic infections at any time in the past, as 
demonstrated by either a patient-reported or physician-documented diagnosis 
AND the initiation of specific treatment if applicable:  
 
• 
Tuberculosis, pulmonary or extrapulmonary 
• 
Non-tuberculous mycobacterial infection, disseminated or extrapulmonary 
• 
Pneumocystis jirovecii pneumonia 
• 
Coccidioidomycosis, disseminated or extrapulmonary 
• 
Cryptococcosis, extrapulmonary 
• 
Cryptosporidiosis or isosporiasis, chronic intestinal (greater than 1 month's 
duration) 
• 
Cytomegalovirus disease (other than liver, spleen, or lymph nodes) and 
including retinitis with loss of vision 
• 
Histoplasmosis, disseminated or extrapulmonary 
• 
Kaposi's sarcoma 
• 
Lymphoma, Burkitt's or immunoblastic, regardless of anatomical location 
• 
Lymphoma, primary of brain 
• 
Progressive multifocal leukoencephalopathy 
• 
Toxoplasmosis of brain 
 
4.2.2 Latent tuberculosis infection, defined as a positive or borderline FDA-approved 
interferon-gamma release assay (IGRA).  
 
4.2.3 Pregnant or breastfeeding. 
 
4.2.4 Active local or systemic infection (defined as requiring systemic antibiotics or 
other medical or surgical treatment) at the time of enrollment. 
 
4.2.5 Use of systemic cancer chemotherapy or radiation therapy, immunosuppressive 
or immunomodulatory therapy (e.g., interferons, tumor necrosis factor 
antagonists, interleukins) or any investigational therapy within 90 days prior to 
study entry or continued indication for such medications. A list of prohibited study 
medications is provided in appendix 1 of the Manual of Operations (MOPS).  
 
NOTE A:  Use of inhaled or nasal steroids, the equivalent of 10 mg of 
prednisone or less per day or a less than 2-week course of steroids 
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NOTE B:  A single course of 1% hydrocortisone cream or equivalent applied up 
to 3 times a day to <10 square inches area for <2 weeks is permitted. 
The investigators will determine if other forms of limited, short-term 
topical steroid use are expected to interfere significantly with the study 
objectives and are therefore exclusionary. 
  
4.2.6 Receipt of a live attenuated vaccine within 30 days prior to study entry or 
expected need for such vaccines at any time during and for 30 days after the 
study. 
 
4.2.7 Known allergy/sensitivity or any hypersensitivity to components of the study drug 
or its formulation. 
 
4.2.8 Active drug or alcohol use or dependence that, in the opinion of the site 
investigator, would interfere with adherence to study requirements. 
 
4.2.9 Serious illness requiring systemic treatment and/or hospitalization within 45 days 
prior to study entry. 
 
4.2.11 Known cirrhosis or severe liver disease (e.g., ascites, encephalopathy, history of 
variceal bleeding). 
 
4.2.12 Active hepatitis B (positive HBsAg, HBV DNA, or HBeAg) or hepatitis C (positive 
HCV antibody and positive HCV RNA in plasma) documented at the screening 
visit.  
 
 
NOTE A:  For purposes of documenting hepatitis B status, an HBsAg or HBV 
DNA obtained in the 6 months prior to and up to the date of the 
screening visit is acceptable EXCEPT for subjects with a positive 
HBcAb at screening (see Note B). A negative HBeAg during the same 
period in the absence of an HBsAg or HBV DNA is not sufficient 
evidence of HBV-negative status. If a clinically obtained test is not 
available at screening, an HBsAg will be drawn together with other 
evaluations at this visit.  
 
 
NOTE B:  For subjects with a positive HBcAb at screening, an HBV DNA below 
the limit of quantification at any time from screening to study entry is 
required. 
 
 
NOTE C:  For purposes of documenting HCV status, a negative HCV antibody 
obtained in the 6 months prior to and up to the date of the screening 
visit is sufficient. For any subject with a positive HCV antibody, an 
HCV RNA measurement is required.  
 
4.2.13 History of diverticulitis, intestinal perforation, distal intestinal obstruction, or lower 
gastrointestinal bleeding.  
 
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4.215 History of a demyelinating disorder such as multiple sclerosis or chronic 
demyelinating polyneuropathy at any time in the past.  
 
4.2.16 A trough level of any protease inhibitor (other than a boosting dose of ritonavir) or 
non-nucleoside reverse transcriptase inhibitor included in the subject’s 
antiretroviral regimen at screening that is below the lower limit of the steady-state 
trough level range observed in published studies, according to Table 2, below.  
 
Table 2: Cutoffs of selected antiretroviral trough levels 
Drug 
Lower limit of range  (levels below this at 
screening are exclusionary) 
Efavirenz(94) 
1 µg/mL 
Nevirapine(94) 
3 µg/mL 
Etravirine(95) 
75 ng/mL 
Rilpivirine(96) 
4 ng/mL 
Atazanavir/r(94) 
0.15 µg/mL 
Darunavir/r(96) 
1036 ng/mL 
Lopinavir/r(94) 
1 µg/mL 
Amprenavir(94) 
0.4 µg/mL 
Fosamprenavir/r(94) 
0.4 µg/mL 
Indinavir/r(94) 
0.1 µg/mL 
Saquinavir SGC/r(94) 
0.1 µg/mL 
Nelfinavir(94) 
0.8 µg/mL 
 
4.2.17 Active malignant disease, other than a resected basal cell carcinoma of the skin. 
 
4.2.18 For subjects who consent to undergo rectal tissue sampling only:  
 
• 
History of a bleeding diathesis of any kind, or contraindication for lower GI 
endoscopy   
 
• 
Major GI tract surgery within 45 days prior to study entry. Minor procedures 
involving only the anal canal such as condyloma ablations, hemorrhoidectomy, 
and anoscopy are permitted if cleared by the responsible surgeon. 
 
 
• 
Continued need for, or use during the 7 days prior to the scheduled flex-sig 
procedure, of the following medications:    
 
o Aspirin, systemic antiplatelet agents,  or more than 4 doses of NSAIDs  
 
 
o Warfarin, heparin, thrombin inhibitors, factor Xa inhibitors, and systemic 
thromobolytics and fibrinolytics. A list of prohibited medications for the flex-
sig procedure can be found in the appendix of the MOPS. A bridge course 
of short-acting low-molecular weight heparin within the 7-day pre-
procedure window in patients receiving a chronic systemic anticoagulant 
who can be safely maintained off anticoagulation for several days is 
permitted if cleared by the subject’s primary healthcare provider and the 
UHCMC Digestive Health Institute.  
   
 
• 
Abnormalities of the colorectal mucosa, or significant colorectal symptoms, 


 
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which in the opinion of the clinician represent a contraindication to biopsy 
(including but not limited to presence of any unresolved injury, infectious or 
inflammatory condition of the local mucosa) 
 
4.3 Study Enrollment Procedures 
 
4.3.1 Study Initiation  
 
Prior to implementation of this protocol, and any subsequent full version 
amendments, the protocol and the protocol consent form(s) must be approved by 
the University Hospitals Case Medical Center IRB and the FDA. Upon receiving 
final approval, the UHCMC CRS will submit all required protocol registration 
documents to the DAIDS Protocol Registration Office (DAIDS PRO) at the 
Regulatory Support Center (RSC). The DAIDS PRO will review the submitted 
protocol registration packet to ensure that all of the required documents have 
been received.  
 
Site-specific informed consent forms (ICFs) WILL NOT be reviewed or approved 
by the DAIDS PRO, and the site will receive an Initial Registration Notification 
when the DAIDS PRO receives a complete registration packet. Receipt of an 
Initial Registration Notification indicates successful completion of the protocol 
registration process. The site will not receive any additional notifications from the 
DAIDS PRO for the initial protocol registration. A copy of the Initial Registration 
Notification will be retained in the site's regulatory files. 
 
Upon receiving final IRB/EC and any other applicable RE approval(s) for an 
amendment, the site will implement the amendment immediately. The site will 
submit an amendment registration packet to the DAIDS PRO at the RCC. The 
DAIDS PRO will review the submitted protocol registration packet to ensure that 
all the required documents have been received. Site-specific ICF(s) WILL NOT 
be reviewed and approved by the DAIDS PRO and the site will receive an 
Amendment Registration Notification when the DAIDS PRO receives a complete 
registration packet. A copy of the Amendment Registration Notification will be 
retained in the site's regulatory files. 
 
For additional information on the protocol registration process and specific 
documents required for initial and amendment registrations, refer to the current 
version of the DAIDS Protocol Registration Manual. 
 
4.3.2 Recruitment 
 
Participants will be recruited from a variety of sources, using the following key 
strategies: 
 
• 
Referrals from clinicians in the Special Immunology Unit 
• 
Direct outreach to patients who are participating in an existing protocol that 
allows for collection of clinical data for research purposes who have provided 
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• 
Participant referrals from existing or past study participants 
• 
Passive self-referral by subjects after receiving IRB-approved publicity 
materials published through print and electronic media 
• 
Referrals from other area HIV practices 
 
Study staff will meet as needed to discuss current recruitment status, targets, 
and strategies.  Staff also will follow-up with all persons who express an interest 
in the study to ensure that screening appointments are scheduled and carried out 
in a timely manner. 
 
To reduce the number of subjects simultaneously exposed to study agent during 
the early stages of the study, the first ten subjects who enroll into the study will 
be scheduled to have their entry visit at least 3 days apart from each other, so 
that no more than two new subjects will initiate study treatment in a given week 
during this period. The decision to remove this gating restriction after the first ten 
subjects will be made by the principal investigators in consultation with the SMC 
and the medical officer. 
 
4.3.3 Subject Registration 
 
Subjects who provide informed consent will be registered to the study according 
to standard UHCMC procedures.  
 
 
4.3.4 Retention 
 
Once participants enroll in this study, the study site will make every effort to 
retain them for the duration of follow-up in order to minimize possible bias 
associated with loss-to-follow-up. The study staff is responsible for developing 
and implementing local standard operating procedures to target this goal.  
Components of such procedures include: 
 
• 
Thorough explanation of the study visit schedule and procedural 
requirements during the informed consent process, and re-emphasis at each 
study visit 
• 
Thorough explanation of the importance of completing all study visits to the 
overall success of the study 
• 
Use of appropriate and timely visit reminder mechanisms (via email and/or 
telephone) 
• 
Immediate and multifaceted follow-up on missed visits 
 
4.4 Coenrollment Guidelines  
 
Coenrollment in any other studies will be decided on a case-by-case basis by the 
protocol chairs.  
 
 


 
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5.0 STUDY TREATMENT  
 
 
Study treatment is defined as tocilizumab (ACTEMRA®) and placebo (Sodium Chloride 
Injection, USP 0.9%). 
 
5.1 Regimens, Administration, and Duration 
 
On study day 0 (study entry), subjects will receive 4 mg/Kg of TCZ intravenously or 
matching placebo, infused over 60 minutes, with a total dose not to exceed 400 mg. The 
final volume of both the placebo and active drug bags will be 100 cc. If the initial dose is 
tolerated and the subject does not experience a grade 3 or greater clinical or laboratory 
adverse event that is thought to be related to study treatment (see section 7.1 for AE 
management), he/she will receive two more doses of 8 mg/Kg of TCZ each, not to 
exceed 800 mg, or matching placebo at weeks 4 and 8.   
 
The subjects will be followed on study through week 20, when they will receive the 
opposite arm of the regimen they received during the first period (i.e., if they were 
assigned to placebo during the first period, they will receive TCZ during the second 
period, and vice versa). The first dose of the second period will generally be 
administered at week 20, but could be given later if the week 20 dose is held for any 
reason.  
 
The weight used for dose calculation will be obtained on the date of each of the study 
agent administration visits.  
 
All doses of study agent will be administered as an inpatient in the Dahms Clinical 
Research Unit (DCRU), and subjects will be observed as inpatients for at least 30 
minutes 
after 
study 
drug 
administration. 
This 
change 
is 
consistent 
with 
recommendations for the use of study drug for clinical purposes(97), and with the 
USPI(69). Subjects will be followed on study through week 40 from the enrollment visit.  
 
5.2 Study Product Formulation and Preparation 
 
Tocilizumab, solution for infusion, reconstituted as per package insert recommendations 
or matching placebo, will be supplied in sterile vials by the investigational pharmacy and 
delivered in a light-opaque pouch ready for administration. Preparation steps are as 
described below:  
 
• 
Step 1. For participants at or above 30 kg, dilute to 100 mL in 0.9% Sodium 
Chloride for intravenous infusion using aseptic technique. Withdraw a volume of 
0.9% Sodium Chloride Injection, USP, equal to the volume of the TCZ solution 
required for the participant’s dose from the infusion bag or bottle. 
• 
Step 2. Slowly add TCZ from each vial into the infusion bag or bottle. To mix the 
solution, gently invert the bag to avoid foaming. 
• 
Step 3. Allow the fully diluted TCZ solution to reach room temperature prior to 
infusion. 
 
For placebo, commercially available 100 mL bags of Sodium Chloride injection, USP 


 
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0.9% will be used. The investigational pharmacy will shroud bags in a light-opaque 
pouch, and label the bags on the outside with the date, patient’s PTID, visit number, and 
sequence number, leaving the tubing out of the pouch for access.   
 
5.3 Pharmacy: Product Supply, Distribution, and Accountability 
 
5.3.1 Study Product Acquisition/Distribution 
 
Tocilizumab (ACTEMRA®) and matching placebo will be obtained commercially.  
 
5.3.2 Study Product Accountability 
 
The site pharmacist is required to maintain complete records of all study 
products. The procedures to be followed are provided in the manual Pharmacy 
Guidelines and Instructions for DAIDS Clinical Trials Networks in the section 
Study Product Management Responsibilities. 
 
5.3.3 Storage 
 
TCZ must be refrigerated at 2°C to 8°C (36°F to 46°F). Do not freeze. Protect the 
vials from light by storage in the original package until time of use. 
 
Once TCZ solution is prepared for infusion it may be stored at 2° to 8°C (36° to 
46°F) or room temperature for up to 24 hours and should be protected from light. 
TCZ solutions do not contain preservatives; therefore, unused product remaining 
in the vials should not be used. Storage conditions for protocol-provided study 
products will include segregation, security, temperature monitoring, and 
sanitation.  Study products will be stored in a limited access area that is locked 
when not in use.  The study products will be accessible only to authorized 
personnel. 
 
5.3.4  Administration 
 
TCZ or placebo will be administered by intravenous infusion. Both the subjects 
and study personnel involved with the administration of study agent or the 
adjudication of adverse events will be blinded to study assignment.  
 
The solution will be inspected visually for particulate matter and discoloration at 
the time of reconstitution and prior to administration. If particulates and 
discolorations are noted, the product will not be used. Fully diluted TCZ solutions 
are compatible with polypropylene, polyethylene and polyvinyl chloride infusion 
bags and polypropylene, polyethylene and glass infusion bottles. The infusion will 
be administered over 60 minutes using an infusion set and pump. The solution 
will not be administered as an intravenous push or bolus. No other drugs will be 
infused concomitantly. 
 
 
 


 
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5.3.5 Dispensing 
 
Study products will be dispensed from the pharmacy to study staff for an enrolled 
participant only upon receipt of a written prescription from an authorized 
prescriber. 
 
5.3.6 Retrieval of Unused Product 
 
Any dispensed but unused product will be handled according to the appropriate 
site and pharmacy procedures and destroyed once it is confirmed that it will not 
be used by the intended recipient. A record of the destruction of the product will 
be maintained by the investigational pharmacy. 
 
5.4 Concomitant Medications 
 
Whenever a concomitant medication is initiated or a dose changed, investigators must 
review the concomitant medications’ and study agents' most recent package inserts, or 
updated information from DAIDS to obtain the most current information on drug 
interactions, contraindications, and precautions. 
 
5.4.1 Prohibited Medications 
 
 
 
The medications that are excluded prior to study entry as stated in the exclusion 
criteria are also prohibited while on study. A list of prohibited medications can be 
found in Appendix 1 of the MOPS.  
 
 


 
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6.0 CLINICAL AND LABORATORY EVALUATIONS 
6.1 Schedule of Events  
 
Subjects must be fasting (defined as nothing by mouth except medications and water for at least 8 hours) for all study visits after the screening visit. Subjects must refrain from 
strenuous exercise and smoking 4 hours prior to BART. Otherwise BART will be rescheduled within the visit window. 
Visit 1: 
Screening
Visit 2:
Baseline1
Visit 3:
Study 
entry
Visit 4:
D3
Visit 5:
W4
Visit 6:
W8
Visit 7:
W10
Visit 8:
W20
(arm shift)
Visit 9:
W20 + 3d
Visit 
10:
W24
Visit 
11:
W28
Visit 
12:
W30
Visit 13:
W40 
(EOS)
Premature 
treatment/study 
discontinuation
Pharmacologic 
interaction 
confirmation
Virologic failure 
confirmation
0 d
3 d
28 d
56 d
70 d
140 d
143 d
168 d
196 d
210 d
280 d
-60 to 
-10 d
-10 to 
0 d
2 to 
4 d
24 to 
32 d
52 to 
60 d
66 to 
74 d
133 to 
147 d
W20 + 2d to 
W20 + 4d
164 to 
172 d
192 to 
200 d
206 to 
214 d
273 to 
287 d
X
Documentation of HIV 
X
Randomization
X
Medical/Medication History
X
X
X
Clinical assessments
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Complete physical exam
X
X
X
X
X
X
Targeted physical exam
X
X
X
X
X
X
X
X
Weight
X
X
X
X
X
X
X
X
X
Height
X
Verification of contraceptive methods
X
X
X
X
X
X
X
X
X
X
X
X
X
Tests processed by the clinical lab
CD4+/CD8+ T cell counts
X
X
X
X
X
X
X
X
X
X
X
X
X
Plasma HIV-1 RNA
X
X
X
X
X
X
X
X
X
X
X
X
X
X2
CBC + diff and platelet count
X
X
X
X
X
X
X
X
X
X
X
X
X
Chemistry panel
X
X
X
X
X
X
X
X
X
X
X
X
X
HBsAg
X3
HBcAb (with reflex HBV DNA if positive)
X3
HBV DNA
X4
X4
X4
X4
X4
X4
X4
X4
X4
HCV Ab
X3
HCV RNA
X5
Interferon-gamma release assay
X6
X6
PT/PTT
X7
X7
X7
For women: rapid pregnancy test
X8
X8
X8
X8
X8
X8
X8
X8
X8
Tests processed by the research labs
Pharmacologic monitoring (ARV and TCZ levels)
X9
X9
X
X
X
X
X
X
X
X
X10
Immunologic monitoring
X
X
X
X
X
X
X
X
X
X
X
X
Transcriptomic monitoring
X
X
X
X
X
X
Metabolic monitoring 
X
X
X
X
X
X
Study agent administration11
X12
X
X
X12
X
X
Cardiovascular monitoring (BART testing)
X
X
X
X
Sigmoidoscopy and biopsies
X13
X13
X13
1 Any of the baseline evaluations can be done at any time in the 10 days prior up to and including the day of entry
3 Only for subjects who do not have one available within 6 months prior to screening
4 Only for subjects who have a positiveHBcAb at screening
5 Only for subjects who do not have one available within 6 months prior to screening AND have a positive HCV Ab
6 And whenever tuberculosis exposure or disease is suspected
7 Only for subjects who will undergo rectosigmoidoscopy and biopsies
8 And whenever pregnancy is suspected
12 First dose in each cycle will be 4 mg/Kg (up to 400 mg). Subsequent doses will be 8 mg/Kg (up to 800 
mg). Dose may be reduced according to lab results.
9 Antiretroviral levels only
13 Only a subset of participants will undergo tissue sampling at each timepoint.
10 Only when the trough level of a protease inhibitor or an NNRTI at 
the previous visit was below the lower limit of the population range (refer to section 4.2.16)
2 Only when the previous HIV-1 RNA is ˃200 copies/mL
Event
Study procedure review; informed consent signature
Within 2 weeks 
of an HIV-1 RNA 
˃200 copies/mL
Within 5 weeks of 
a trough PI/NNTTI 
level below 
threshold
Timepoint and window
11 Frequent vital sign monitoring will be a part of study agent administration visits


 
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6.2 Timing of Evaluations 
 
6.2.1 Overview of Study Visits 
 
In addition to any interim visits that may occur in response to clinical events 
during the study, the following visits will take place for study participants: 
 
Visit 1: 
 
Screening Visit 
Visit 2: 
 
Baseline Visit 
Visit 3: 
 
Day 0 Study Entry - Dosing Visit 
Visit 4:  
 
Day 3 F/U 
Visit 5: 
 
Week 4 - Dosing Visit 
Visit 6: 
 
Week 8 - Dosing Visit 
Visit 7: 
 
Week 10 – Primary Endpoint Visit 
Visit 8: 
 
Week 20- Crossover Dosing Visit 
Visit 9: 
 
Week 20 + 3 Days F/U 
Visit 10: 
 
Week 24 - Dosing Visit 
Visit 11: 
 
Week 28 - Dosing Visit 
Visit 12: 
 
Week 30 - Primary Endpoint Visit 
Visit 13: 
 
Week 40 End of Study Visit 
 
Participants will have a 12-week washout period before crossover to the next 
arm. 
 
Prescreening via a phone call will take place with potential participants, and 
those interested in the study can request that the informed consent documents 
be mailed out to them prior to the Screening Visit.  
 
6.2.2 Visit 1: Screening Evaluations (Day -60 to -10) 
 
            
Both screening and baseline evaluations must occur prior to the subject’s starting 
any study medications, treatments or interventions. Written informed consent will 
be obtained before any procedures are initiated. For participants who do not 
meet the eligibility criteria, screening will be discontinued once ineligibility is 
determined. Participants not meeting the eligibility criteria may be rescreened at 
a later date, if appropriate (e.g., to allow washout of a discontinued prohibited 
medication). 
 
            
Screening evaluations to determine eligibility must be completed within 60 days, 
but no less than 10 days prior to study entry unless otherwise specified. 
 
 
 
NOTE:  Subjects do not need to be fasting for the screening evaluations. 
 
 
 
 
 
 
 
 


 
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Table 3: Visit 1 (Screening) 
Component 
Procedure/Analysis 
Administrative  
•     Obtain written informed consent 
•     Assign participant ID (PTID) 
•     Assess eligibility  
•    Provide reimbursement for study visit 
•    Confirm documentation of HIV status 
•     Obtain locator information 
Clinical  
•     Record medical history 
•     Record medication history 
•     Verify method(s) of contraception 
•     Perform complete physical exam 
Blood 
specimens  
(~60 mL) 
•     Collect blood specimens and send to the clinical laboratory for: 
o    CD4+/CD8+ T cell counts 
o    Plasma HIV-1 RNA 
o    CBC with differential and platelets 
o    Chemistry panel as defined in 6.3.5.1 
o    Hepatitis testing (if no results available within prior 6 months), including: 
-    Hepatitis B surface antigen (HBsAg) 
-   Hepatitis B core antibody (HBcAb, with reflex HBV DNA if positive) 
-    HCV Ab 
-    HCV RNA (only if HCV Ab+) 
o    Interferon-gamma release assay (IGRA) 
o    PT/PTT (for subjects participating in rectosigmoid specimen collection only) 
o    Qualitative hCG for women of childbearing potential, if not performed on urine 
•     Collect blood specimens and send to the research laboratory for: 
o    Pharmacologic studies (ARV levels only) 
Urine specimens 
•     Collect urine sample for qualitative hCG for women of childbearing potential, if not 
performed on blood 
 
6.2.3  Visit 2: Baseline Evaluations (Day -10 to 0) 
 
Baseline evaluations must be completed within the 10 days prior to entry 
evaluations unless otherwise specified. If needed for ease of scheduling, 
baseline evaluations may be conducted over more than one day, as long as all 
evaluations are completed within the visit’s window. Baseline evaluations may be 
conducted on the same day as study entry.  
 
NOTE A:  
Subjects will be asked to fast for the baseline evaluations.  Fasting 
is defined as nothing by mouth except medications and water for 
at least 8 hours prior to the visit, but this visit will not be 
rescheduled if the subject is not fasting. Instead, this deviation will 
be recorded in the CRF. 
 
NOTE B:  
All laboratory, cardiovascular, and gastrointestinal sampling 
procedures at the baseline visit must be completed before the first 
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NOTE C:  
Subjects will be asked to refrain from smoking and from strenuous 
exercise for at least 4 hours prior to the baseline visit. BART 
testing will be rescheduled if the subject smoked or exercised 
vigorously in the 4 hours prior to BART. 
 
Table 4: Visit 2 (Baseline) 
Component 
Procedure/Analysis 
Administrative  
•     Confirm informed consent and eligibility 
•     Confirm/update locator information 
•     Provide available test results 
•     Provide reimbursement for study visit  
Clinical  
•     Review/update medical history 
•     Review/update medication history 
•     Verify method(s) of contraception 
•     Perform targeted physical exam if indicated 
Cardiovascular studies 
•    Perform brachial arterial reactivity testing (BART) 
Rectosigmoid specimens (If 
subject has consented to 
rectosigmoid biopsies) 
•     Confirm that subject followed instructions for preparation, including enemas  
•     Collect rectosigmoid biopsies (~20) via flexible sigmoidoscopy  
 
6.2.4    Visit 3: Study Entry (Day 0) 
 
All entry evaluations must occur prior to the administration of the first dose of 
study agent. Randomization will occur at the beginning of this visit. 
Randomization procedures are described in the MOPS. Baseline evaluations 
may be completed on the same day as study entry.  
 
NOTE:  Subjects will be asked to fast for the entry (day 0) and all post-entry 
study visits, defined as nothing by mouth except medications and water for at 
least 8 hours prior to the visits, but these visits will not be rescheduled if the 
subject is not fasting. Instead, this deviation will be recorded in the CRF. 
 
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Table 5: Visit 3 (Study entry) 
Component 
Procedure/Analysis 
Administrative  
•     Confirm and complete randomization 
•     Confirm/update locator information 
•     Provide available test results 
•     Provide reimbursement for study visit  
Pre-dose Procedures 
Clinical  
•     Verify method(s) of contraception 
•     Record any AEs and concomitant medications  
•     Review/update medical and medication history 
•     Perform complete physical exam, including height and weight 
Blood 
specimens (~120 
mL)  
•     Collect blood specimens and send to the clinical laboratory for: 
o    CD4+/CD8+ T cell counts 
o    Plasma HIV-1 RNA 
o    CBC with differential and platelets 
o    Chemistry panel as defined in 6.3.5.1 
o    Qualitative hCG for women of childbearing potential, if not performed on urine 
o    HBV DNA (for HBcAb-positive subjects only)  
•     Collect blood specimens and send to the research laboratory for: 
o    Pharmacologic studies (ARV levels only) 
o    Immunologic studies  
o    Transcriptomic studies 
o    Metabolic studies 
Urine specimens  •     Collect urine sample for qualitative hCG for women of childbearing potential, if not 
performed on blood 
Study product 
dose 
•     Administer 4 mg/kg dose of TCZ or placebo via intravenous infusion over 60 minutes 
 
6.2.5 
Visit 4: Day 3 (+/-1 day) 
 
Table 6: Visit 4 (Day 3) 
Component 
Procedure/Analysis 
Administrative  
•     Confirm/update locator information 
•     Provide available test results 
•     Provide reimbursement for study visit  
Clinical  
•     Verify method(s) of contraception 
•     Record any AEs and concomitant medications  
•     Perform targeted physical exam if indicated 
Blood 
specimens  
(~60 mL) 
•     Collect blood specimens and send to the clinical laboratory for: 
o    CD4+/CD8+ T cell counts 
o    Plasma HIV-1 RNA 
o    CBC with differential and platelets 
o    Chemistry panel as defined in 6.3.5.1 
•    Collect blood specimens and send to the research laboratory for:  
o    Immunologic studies  


 
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6.2.6 Visit 5: Week 4 (+/-4 days) 
 
Table 7: Visit 5 (Week 4) 
Component 
Procedure/Analysis 
Administrative  
•     Confirm/update locator information 
•     Provide available test results 
•     Provide reimbursement for study visit  
Pre-dose Procedures 
Clinical  
•     Verify method(s) of contraception 
•     Record any AEs and concomitant medications  
•     Perform targeted physical exam if indicated, obtain weight 
Blood specimens  
(~60 mL) 
•     Collect blood specimens and send to the clinical laboratory for: 
o    CD4+/CD8+ T cell counts 
o    Plasma HIV-1 RNA 
o    CBC with differential and platelets 
o    Chemistry panel as defined in 6.3.5.1 
o    Qualitative hCG for women of childbearing potential, if not performed on urine 
o    HBV DNA (for HBcAb-positive subjects only)  
•    Collect blood specimens and send to the research laboratory for: 
o    Pharmacologic studies 
o    Immunologic studies  
Urine specimens  
•     Collect urine sample for qualitative hCG for women of childbearing potential, if not 
performed on blood 
Study product dose 
•     Administer 8 mg/kg dose of TCZ or placebo via intravenous infusion over 60 minutes 
 
 
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6.2.7 Visit 6: Week 8 (+/-4 days) 
 
Table 8: Visit 6 (Week 8) 
Component 
Procedure/Analysis 
Administrative  
•     Confirm/update locator information 
•     Provide available test results 
•     Provide reimbursement for study visit  
Pre-dose Procedures 
Clinical  
•     Verify method(s) of contraception 
•     Record any AEs and concomitant medications  
•     Perform targeted physical exam if indicated, obtain weight 
Blood specimens  
(~60 mL) 
•     Collect blood specimens and send to the clinical laboratory for: 
o    CD4+/CD8+ T cell counts 
o    Plasma HIV-1 RNA 
o    CBC with differential and platelets 
o    Chemistry panel as defined in 6.3.5.1 
o    PT/PTT(for subjects participating in rectosigmoid specimen collection only) 
o    Qualitative hCG for women of childbearing potential, if not performed on urine 
o    HBV DNA (for HBcAb-positive subjects only)  
•    Collect blood specimens and send to the research laboratory for: 
o    Pharmacologic monitoring 
o    Immunologic monitoring 
Urine specimens  
•     Collect urine sample for qualitative hCG for women of childbearing potential, if not 
performed on blood 
Study product dose 
•     Administer 8 mg/kg dose of TCZ or placebo via intravenous infusion over 60 minutes 
 
6.2.8 Visit 7: Week 10 (+/-4 days) 
 
NOTE: Subjects will be asked to refrain from smoking and from strenuous 
exercise for at least 4 hours prior to the week 10 visit. BART testing will be 
rescheduled if the subject smoked or exercised vigorously in the 4 hours prior to 
BART.  
 
If needed for ease of scheduling, week 10 evaluations may be conducted over 
more than one day, as long as all evaluations are completed within the visit’s 
window. 
 
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Table 9: Visit 7 (Week 10) 
Component 
Procedure/Analysis 
Administrative  
•     Confirm/update locator information 
•     Provide available test results 
•     Provide reimbursement for study visit  
Clinical  
•     Verify method(s) of contraception 
•     Record any AEs and concomitant medications  
•     Perform complete physical exam 
Blood specimens  
(~120 mL) 
•     Collect blood specimens and send to the clinical laboratory for: 
o    CD4+/CD8+ T cell counts 
o    Plasma HIV-1 RNA 
o    CBC with differential and platelets 
o    Chemistry panel as defined in 6.3.5.1 
o    Interferon-gamma release  assay (IGRA) 
o    Qualitative hCG for women of reproductive potential, if not performed on 
urine 
o    HBV DNA (for HBcAb-positive subjects only)  
•    Collect blood specimens and send to the research laboratory for: 
o    Pharmacologic monitoring 
o    Immunologic monitoring 
o    Transcriptomic monitoring 
o    Metabolic monitoring  
Cardiovascular studies 
•    Perform brachial arterial reactivity testing (BART) 
Urine specimens  
•     Collect urine sample for qualitative hCG for women of childbearing potential, if 
not performed on blood 
Rectosigmoid specimens 
(If subject has consented 
to rectosigmoid biopsies) 
•     Confirm that subject followed instructions for preparation, including enemas  
•     Collect rectosigmoid biopsies (~20) via flexible sigmoidoscopy  
 
6.2.9  
Visit 8: Week 20 Crossover (+/- 7 days)  
 
NOTE: Subjects will be asked to refrain from smoking and from strenuous 
exercise for at least 4 hours prior to the week 20 visit. BART testing will be 
rescheduled if the subject smoked or exercised vigorously in the 4 hours prior to 
BART.  
 
If needed for ease of scheduling, week 20 evaluations may be conducted over 
more than one day, as long as all evaluations are completed within the visit’s 
window. 
 
 
 
 
 
 
 
 
 


 
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Table 10: Visit 8 (Week 20, crossover) 
Component 
Procedure/Analysis 
Administrative  
•     Confirm/update locator information 
•     Provide available test results 
•     Provide reimbursement for study visit  
Pre-dose Procedures 
Clinical  
•     Verify method(s) of contraception 
•     Record any AEs and concomitant medications  
•     Perform complete physical exam, obtain weight 
Blood 
specimens (~120 
mL) 
•     Collect blood specimens and send to the clinical laboratory for: 
o    CD4+/CD8+ T cell counts 
o    Plasma HIV-1 RNA 
o    CBC with differential and platelets 
o Chemistry panel as defined in 6.3.5.1 
o    Qualitative hCG for women of childbearing potential, if not performed on urine 
o    HBV DNA (for HBcAb-positive subjects only)  
•    Collect blood specimens and send to the research laboratory for: 
o    Pharmacologic studies 
o    Immunologic studies  
o    Transcriptomic studies 
o    Metabolic studies 
Cardiovascular 
studies 
•    Perform brachial arterial reactivity testing (BART) 
Urine specimens  •     Collect urine sample for qualitative hCG for women of childbearing potential, if not 
performed on blood 
Study product 
dose 
•     Administer 4 mg/kg dose of TCZ or placebo via IV infusion over 60 minutes 
 
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6.2.10 Visit 9: Week 20 and 3 Days (+/- 1 day)      
 
Table 11: Visit 9 (Week 20 + 3 days) 
Component 
Procedure/Analysis 
Administrative  
•     Confirm/update locator information 
•     Provide available test results 
•     Provide reimbursement for study visit 
Clinical  
•     Verify method(s) of contraception 
•     Record any AEs and concomitant medications  
•     Perform targeted physical exam if indicated 
Blood 
specimens  
(~60 mL) 
•     Collect blood specimens and send to the clinical laboratory for: 
o    CD4+/CD8+ T cell counts 
o    Plasma HIV-1 RNA 
o    CBC with differential and platelets 
o    Chemistry panel as defined in 6.3.5.1 
•         Collect blood specimens and send to the research laboratory for:  
o    Immunologic studies 
 
 
6.2.11 Visit 10: Week 24 (+/-4 days) 
 
Table 12: Visit 10 (Week 24) 
Component 
Procedure/Analysis 
Administrative  
•     Confirm/update locator information 
•     Provide available test results 
•     Provide reimbursement for study visit  
Pre-dose Procedures 
Clinical  
•     Verify method(s) of contraception 
•     Record any AEs and concomitant medications  
•     Perform targeted physical exam if indicated; obtain weight 
Blood 
specimens  
(~60 mL) 
•     Collect blood specimens and send to the clinical laboratory for: 
o    CD4+/CD8+ T cell counts 
o    Plasma HIV-1 RNA 
o    CBC with differential and platelets 
o    Chemistry panel as defined in 6.3.5.1 
o    Qualitative hCG for women of childbearing potential, if not performed on urine 
o    HBV DNA (for HBcAb-positive subjects only)  
•    Collect blood specimens and send to the research laboratory for: 
o    Pharmacologic studies 
o    Immunologic studies  
Urine specimens  •     Collect urine sample for qualitative hCG for women of childbearing potential, if not 
performed on blood 
Study product 
dose 
•     Administer 8 mg/kg dose of TCZ or placebo via intravenous infusion over 60 minutes 
 
 
 


 
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6.2.12 Visit 11: Week 28 (+/-4 days) 
 
Table 13: Visit 11 (Week 28) 
Component 
Procedure/Analysis 
Administrative  
•     Confirm/update locator information 
•     Provide available test results 
•     Provide reimbursement for study visit  
Pre-dose Procedures 
Clinical  
•     Verify method(s) of contraception 
•     Record any AEs and concomitant medications  
•     Perform targeted physical exam if indicated; obtain weight 
Blood 
specimens  
(~60 mL) 
•     Collect blood specimens and send to the clinical laboratory for: 
o    CD4+/CD8+ T cell counts 
o    Plasma HIV-1 RNA 
o    CBC with differential and platelets 
o    Chemistry panel as defined in 6.3.5.1 
o    PT/PTT(for subjects participating in rectosigmoid specimen collection only) 
o    Qualitative hCG for women of childbearing potential, if not performed on urine 
o    HBV DNA (for HBcAb-positive subjects only)  
•    Collect blood specimens and send to the research laboratory for: 
o    Pharmacologic monitoring 
o    Immunologic monitoring 
Urine 
specimens  
•     Collect urine sample for qualitative hCG for women of childbearing potential, if not performed 
on blood 
Study product 
dose 
•     Administer 8 mg/kg dose of TCZ or placebo via intravenous infusion over 60 minutes 
 
6.2.13 Visit 12: Week 30 (+/-4 days) 
 
NOTE: Subjects will be asked to refrain from smoking and from strenuous 
exercise for at least 4 hours prior to the week 30 visit. BART testing will be 
rescheduled if the subject smoked or exercised vigorously in the 4 hours prior to 
BART.  
 
If needed for ease of scheduling, week 30 evaluations may be conducted over 
more than one day, as long as all evaluations are completed within the visit’s 
window. 
 
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Table14: Visit 12 (Week30) 
Component 
Procedure/Analysis 
Administrative  
•     Confirm/update locator information 
•     Provide available test results 
•     Provide reimbursement for study visit  
Clinical  
•     Verify method(s) of contraception 
•     Record any AEs and concomitant medications  
•     Perform complete physical exam; obtain weight 
Blood specimens  
(~120 mL) 
•     Collect blood specimens and send to the clinical laboratory for: 
o    CD4+/CD8+ T cell counts 
o    Plasma HIV-1 RNA 
o    CBC with differential and platelets 
o    Chemistry panel as defined in 6.3.5.1 
o    Qualitative hCG for women of childbearing potential, if not performed on urine 
o    HBV DNA (for HBcAb-positive subjects only)  
•    Collect blood specimens and send to the research laboratory for: 
o    Pharmacologic monitoring 
o    Immunologic monitoring 
o    Transcriptomic monitoring 
o    Metabolic monitoring  
Urine specimens  
•     Collect urine sample for qualitative hCG for women of childbearing potential, if not 
performed on blood 
Cardiovascular studies 
•    Perform brachial arterial reactivity testing (BART) 
Rectosigmoid specimens 
(If subject has consented 
to rectosigmoid biopsies) 
•     Confirm that subject followed instructions for preparation, including enemas  
•     Collect rectosigmoid biopsies (~20) via flexible sigmoidoscopy  
 
6.2.14 Visit 13 (End of Study): Week 40 (+/- 7 days) 
 
Table 15: Visit 13 (Week 40, end of study) 
Component 
Procedure/Analysis 
Administrative  
•     Confirm/update locator information 
•     Provide available test results 
•     Provide reimbursement for study visit  
Clinical  
•     Verify method(s) of contraception 
•     Record any AEs and concomitant medications  
•     Perform targeted physical exam if indicated; obtain weight 
Blood specimens 
(~120 mL) 
•     Collect blood specimens and send to the clinical laboratory for: 
o    CD4+/CD8+ T cell counts 
o    Plasma HIV-1 RNA 
o    CBC with differential and platelets 
o    Chemistry panel as defined in 6.3.5.1 
o    HBV DNA (for HBcAb-positive subjects only)  
•    Collect blood specimens and send to the research laboratory for: 
o    Immunologic studies  
o    Transcriptomic studies 
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6.2.15 Interim Contacts and Visits 
 
Interim visits may be performed at any time during the study.  All interim contacts 
and visits will be documented in the source documentation and on applicable 
case report forms.   
 
Some interim visits may occur for administrative reasons. For example, the 
participant may have questions for study staff. Other interim contacts and visits 
may occur in response to AEs experienced by study participants.  When interim 
contacts or visits are completed in response to participant reports of AEs, study 
staff will assess the reported event clinically and provide or refer the participant 
to appropriate medical care.   
 
When a trough level of a protease inhibitor or non-nucleoside reverse 
transcriptase inhibitor that is part of the subject’s regimen is found to be below 
the pre-specified threshold (refer to section 4.2.16), a pharmacologic interaction 
confirmation visit will occur and a repeat antiretroviral level measurement will be 
obtained, unless the confirmation visit coincides with another scheduled visit. 
When a plasma HIV RNA level is above 200 copies/mL in a subject who reports 
continued adherence to his/her antiretroviral regimen, a virologic failure 
confirmation visit will occur and only a specimen for repeat plasma HIV RNA 
measurement will be obtained, unless the confirmation visit coincides with 
another scheduled visit. 
 
Table 16: Interim contacts and visits 
Component 
Procedure/Analysis 
Administrative 
•     Review/update locator information 
•     Provide test results, if applicable 
  
•     Record any AEs and concomitant medications  
•     Perform targeted physical exam if indicated 
Blood Specimens 
(~20 mL) 
•     If pharmacologic interaction confirmation, collect blood specimens and send to the 
research laboratory for: 
o    Pharmacologic studies 
•     If virologic failure confirmation, collect blood specimens and send to the clinical 
laboratory for: 
o    Plasma HIV-1 RNA 
Additional specimens 
Collect appropriate specimens and perform testing as clinically indicated 
 
 
6.2.16 
Participants Who Become Pregnant 
 
Study staff will capture pregnancies on study documents. Women who become 
pregnant will be considered to be on-study until the outcome of the pregnancy is 
known. Women who become pregnant will be encouraged to enroll in the 
Actemra® pregnancy registry by calling 1-877-311-8972. Protocol-specified 
procedures will continue except: 
 


 
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• 
Product administration 
• 
Verification of contraception 
• 
Qualitative hCG 
• 
Flexible sigmoidoscopy and biopsies 
• 
BART 
 
6.2.17 
Discontinuation Evaluations 
 
If the participant withdraws or is withdrawn from the study after receiving study 
product, a premature treatment/study discontinuation visit will be conducted if 
possible. 
 
6.2.17.1 Final Contact 
 
After the end of study visit or early termination visit, a final contact may 
be required to provide laboratory test results or follow-up regarding an 
AE. In addition, for participants who become pregnant during study 
participation, an additional contact may be required to ascertain the 
participant’s pregnancy outcome. All final contacts will be documented 
in participant study records.   
 
6.2.17.2 Evaluations for Registered Subjects Who Do Not Start Study 
Treatment 
 
A subject who does not start study treatment will be taken off study 
with no further evaluations required, and replaced by the next subject 
who attends the baseline visit. Demographic data, clinical diagnosis 
data, and screening laboratory results will be retained on all subjects 
who are not enrolled for any reason after the screening visit and who 
have consented to have basic demographic information stored for this 
purpose.  
 
6.2.17.3 Premature Study Treatment Discontinuation Evaluations  
 
Premature 
discontinuation 
of 
study 
treatment 
is 
defined 
as 
permanently discontinuing all study treatment prior to week 30.   
 
Subjects who prematurely discontinue study treatment will have the 
premature treatment/study discontinuation evaluations performed 
within 2 weeks and no later than the next scheduled study visit. 
Subjects who prematurely discontinue study treatment will be 
encouraged to continue on study/off study treatment and receive all 
study evaluations per section 6.1 through week 40. 
 
6.2.17.4 Premature Study Discontinuation Evaluations  
 
Subjects who discontinue prematurely from the study prior to the final 
visit 
will 
have 
the 
premature 
treatment/study 
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evaluations performed as per section 6.1 as soon as possible after the 
study team learns about study discontinuation.  
 
Table 17: Premature treatment/study discontinuation visit 
Component 
Procedure/Analysis 
Administrative  
•     Confirm/update locator information 
•     Provide available test results 
•     Provide reimbursement for study visit 
Clinical  
•     Record any AEs and concomitant medications  
•     Perform complete physical exam 
Blood specimens 
(~120 mL) 
•     Collect blood specimens and send to the clinical laboratory for: 
o    CD4+/CD8+ T cell counts 
o    Plasma HIV-1 RNA 
o    CBC with differential and platelets 
o    Chemistry panel as defined in 6.3.5.1 
•    Collect blood specimens and send to the research laboratory for: 
o    Pharmacologic studies 
o    Immunologic studies  
o    Transcriptomic studies 
o    Metabolic studies 
 
6.3 Instructions for Evaluations 
 
All clinical and laboratory information required by this protocol is to be present in the 
source documents. Results of all approved laboratory tests performed as part of the 
study will be provided to the subjects’ physicians, and any resulting clinical action will be 
taken by the subject and their physician without interference from the study personnel.   
 
All stated evaluations are to be recorded on the CRF and keyed into the database 
unless otherwise specified. This includes events that meet any of the following 
International Conference on Harmonisation (ICH) definitions for a serious adverse 
event (SAE): 
 
• 
Results in death 
• 
Is life-threatening 
• 
Requires inpatient hospitalization or prolongation of existing hospitalization 
• 
Results in persistent or significant disability/incapacity  
• 
Is a congenital anomaly/birth defect 
• 
May jeopardize the subject or may require intervention to prevent one of the events 
listed above, even if not immediately life-threatening or resulting in death or 
hospitalization.   
 
To grade diagnoses, signs and symptoms, and laboratory results, the DAIDS Table for 
Grading the Severity of Adult and Pediatric Adverse Events, Version 2.0, November 
2014, available at http://rsc.tech-res.com/safetyandpharmacovigilance, will be used.  
 
 


 
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6.3.1 Documentation of HIV 
 
 
Refer to section 4.1.5 regarding assay requirements for HIV-1 documentation. 
HIV-1 documentation is not recorded on the CRF. 
 
6.3.2 Medical History 
 
 
The medical history must include all diagnoses that were either established 
within 45 days prior to or ongoing at the time of enrollment. Any allergies to any 
study medications and their formulations must be documented. All elements of 
the medical history will be recorded on the CRF. 
            
 
6.3.3 Medication History 
 
 
 
A medication history must be present, including start and stop dates. The table 
below lists the medications that must be included in the history to be recorded on 
the CRFs. 
 
Table 18. Medications to be recorded 
Medication Category 
Timeframe 
Antiretroviral medications 
Complete history 
Immune-based therapies 
Within 90 days prior to study entry 
Drugs for treatment or prevention of 
opportunistic infections 
Within 96 weeks prior to study entry 
Vaccines 
Within 30 days prior to study entry 
All other prescription and non-
prescription medications 
Within 90 days prior to entry 
 
6.3.4 Clinical Assessments 
 
6.3.4.1 Complete Physical Exam  
 
At the screening, study entry, week 10, week 20, and week 30 visits, a 
complete physical examination will be performed. A complete physical 
exam is to include at a minimum an examination of the skin, head, 
mouth, and neck; auscultation of the heart and lungs; abdominal exam; 
and examination of the lower extremities for edema. The complete 
physical exam will also include vital signs (temperature, heart rate, 
respiration rate, and blood pressure).  
 
6.3.4.2 
Targeted Physical Exam 
 
At all other visits, a targeted physical exam will be performed. A 
targeted physical exam is directed to the site or organ system involved 
in any previously identified or new signs or symptoms that the subject 
has experienced since the last visit. This exam also includes vital signs 
(temperature, heart rate, respiration rate, and blood pressure). 
 


 
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6.3.4.3 
Additional Vital Sign Monitoring at Study Agent Administration Visits 
 
In addition to vital signs recorded as part of either targeted or complete 
physical exams, vital signs (temperature, heart rate, respiration rate, 
and blood pressure) will be measured and recorded every 15 minutes 
for 60 minutes after beginning infusion of the study agent and 30 
minutes after completion of infusion at the entry and week 20 visits. 
Vital signs will also be measured and recorded every 30 minutes for 90 
minutes from the beginning of study agent infusion at the week 4, 8, 
24, and 28 visits. 
 
6.3.4.4 
Height 
 
Height without shoes in centimeters will be recorded on the CRF at 
entry. 
 
6.3.4.5 
Weight 
 
Weight without shoes in kilograms will be recorded on the CRF at each 
TCZ administration visit and at the end of study visit.  
 
6.3.4.6 Signs and Symptoms 
 
At entry, all signs and symptoms, regardless of grade, that occurred 
within 45 days before entry will be recorded in the source documents.  
Post-entry, only grade ≥ 2 signs and symptoms, or those that led to a 
change in treatment, regardless of grade, will be recorded on the CRF. 
 
6.3.4.7 
Diagnoses 
 
After study entry, all new diagnoses established while on study will be 
recorded on the CRF, and relationship to study agent will be assessed. 
 
6.3.4.8 
Concomitant Medications 
 
Concomitant prescription or over-the counter medications initiated or 
discontinued since the last visit will be recorded on the source 
documents. 
 
6.3.4.9 
Study Treatment Modifications 
 
All study drug modifications, including initial doses or protocol-
mandated modifications at each visit will be recorded. Any permanent 
discontinuation of treatment will be recorded.  
 
 
 
 


 
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6.3.4.10 Antiretroviral Medications 
 
All modifications to antiretroviral medications post-entry will be 
recorded on the CRF. If the modification includes discontinuation of 
antiretrovirals, the rules for treatment discontinuation (section 8) must 
be followed. 
 
 
6.3.5 Laboratory Evaluations 
 
At entry and at week 20, record hemoglobin, platelet count, ANC, WBC, 
hematocrit, serum creatinine, AST, ALT, serum glucose, total cholesterol, LDL 
cholesterol, and triglyceride values, regardless of grade, on the CRFs. After entry 
and at times other than week 20, only laboratory values grade 2 or higher must 
be recorded on the CRFs. 
 
6.3.5.1 Clinical Laboratory Tests  
 
All clinical labs as indicated in section 6.1 and listed below will be 
processed in the CLIA-certified clinical laboratory of University Hospitals 
Case Medical Center. Specimens for all other laboratory tests for 
pharmacologic, transcriptomic, immunologic, and metabolic/metabolomics 
studies will be received, aliquoted, and distributed by the Lederman-Sieg 
laboratory. Research laboratory studies are described in the next several 
sections. Clinical laboratories include:  
  
• 
CBC with differential and platelet count. This test will be submitted 
and results obtained in real time. 
• 
Metabolic panel, including at least glucose, BUN, creatinine, sodium, 
potassium, chloride, bicarbonate, total and direct bilirubin, AST, ALT, 
alkaline phosphatase, total cholesterol, triglycerides, and LDL 
cholesterol. This test will be submitted and results obtained in real 
time. 
• 
For subjects participating in the rectosigmoid specimen collection, 
prothrombin time (PT), international normalized ratio, and partial 
thromboplastin time (PTT). This test will be submitted and results 
obtained in real time. 
• 
HIV-1 RNA testing will be done using an FDA-approved method with a 
lower limit of detection ≤50 copies/mL. This test will be submitted in 
real time, but the turnaround time is approximately 3 days. 
• 
HBsAg, HBcAb with reflex HBV DNA, HCV Ab, and HCV RNA will be 
performed using FDA-approved kits as needed to determine eligibility 
(refer to section 4.2.12). These tests will be submitted in real time. 
Results will be obtained, however, prior to study entry.  
• 
The QuantiFERON®-TB Gold in-tube test will be used for tuberculosis 
screening and processed in the clinical laboratory of University 
Hospitals of Cleveland, according to the manufacturer’s instructions. 
Whole blood will be processed within 16 hours of drawing. Subjects 
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not eligible to enroll, regardless of previous treatment history. Refer to 
the MOPS for details about timing of specimen collection, tube type, 
blood volume required and processing. This test will be submitted in 
real time. Results will be obtained prior to study entry and prior to the 
week 20 dose administration. 
 
Additionally, for women of reproductive potential, an FDA-approved rapid 
pregnancy test (either blood or urine) will be performed at study entry, at 
each dosing visit, and whenever pregnancy is suspected. At each dosing 
visit, administration of study agent will begin only after a negative 
pregnancy test result has been obtained. 
 
6.3.5.2 Pharmacologic Studies 
 
6.3.5.2.1 Tocilizumab levels 
 
Tocilizumab (TCZ) levels in plasma will be quantified by ELISA 
at each post-entry study visit, except the day 3 and week 20+ 3 
days visits, in the Lederman-Sieg laboratory. Before testing 
samples derived from the study, the assay will be fully validated 
in the Lederman-Sieg lab. This testing will be done in batch. 
Refer to the MOPS for details about timing of specimen 
collection, tube type, blood volume required and processing. 
 
6.3.5.2.2 Antiretroviral Level Monitoring 
 
Trough levels of protease inhibitors and non-nucleoside reverse 
transcriptase inhibitors will be sent in real time to the laboratory 
of Edmund Capparelli at the University of California San Diego 
Antiviral Research Center for processing. Every effort will be 
made to coordinate dosing times to obtain specimens at a time 
point as close to the end of the dosing interval as possible. 
Dates and times of the previous three doses of all 
antiretrovirals will be recorded on the CRF. A specimen for 
antiretroviral levels will not be collected if a subject has been off 
antiretrovirals for 72 hours or longer prior to the visit. Refer to 
the MOPS for details about timing of specimen collection, tube 
type, blood volume required and processing. 
 
Specimens for pharmacologic monitoring will be submitted as 
they are collected, but turnaround time is expected to be 2-3 
weeks, not including shipping times. Results will be recorded 
on the CRF upon receipt and reviewed by investigators by the 
following workday. If trough levels of a protease inhibitor or a 
non-nucleoside reverse transcriptase inhibitor are found to be 
lower than the inferior limit of the range observed in previous 
population studies for that agent (refer to section 4.2.16 for 
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value below the cutoff. This repeat draw can occur at the time 
of the subsequent scheduled visit if within the 5-week window 
from the initial lower-than-expected value.   
 
6.3.5.3 Transcriptomic Studies 
 
Gene expression profiles on whole blood, sorted naïve and central 
memory CD4+ T cells, and monocyte subsets, will be constructed using 
the Illumina platform from specimens obtained at the study visits indicated 
in section 6.1. Additionally, mucosal snips and single-cell suspensions 
prepared by collagenase digestion from rectosigmoid biopsies from 
subject participating in the flex-sig substudy will be preserved in RNAlater 
for RNAseq analysis. All gene expression profiling will be performed in 
the laboratory of Dr. Rafick-Pierre Séklay at the Vaccine & Gene Therapy 
Institute (VGTI) of Florida in Port St. Lucie, FL. Refer to the MOPS for 
details about timing of specimen collection, tube type, blood volume 
required and processing. 
 
PBMCs will be isolated and frozen according to the HANC Cross-Network 
Consensus Cryopreservation SOP and aliquoted at 5 to10x106 cells per 
vial in one ml. Specimens for transcriptomic studies will be shipped and 
processed in batch. Refer to the MOPS for details about timing of 
specimen collection, tube type, blood volume required and processing.    
 
6.3.5.4 Metabolic Studies 
 
 
6.3.5.4.1 Lipid fractions and other markers of cardiovascular risk 
 
Conventional lipid fractions, ApoA1, ApoB, Lp(a), OxLDL, 
piHDL, PON1, the adipokines adiponectin and leptin, and 
insulin resistance as reflected by HOMA-IR and resistin levels 
will be measured in serum or plasma. All the metabolic studies 
will be performed in batch at the end of the study, except for 
conventional lipid fractions done in the clinical laboratory as 
part of the comprehensive metabolic panel (Chem23), as 
described in 6.3.5.1. Refer to the MOPS for details about timing 
of specimen collection, tube type, blood volume required and 
processing.    
 
6.3.5.4.2 Metabolomic profile 
 
Levels of acylcarnitine, amino acid and free carnitine 
metabolites in plasma and metabolites modulated by IL-6 
blockade will be analyzed in collaboration with Metabolon, Inc. 
(Durham, NC) using liquid chromatography–mass spectrometry 
(LC-MS) and gas chromatography–mass spectrometry (GC-
MS). All metabolomics assays will be performed in batch and 
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section 6.1. Samples will be prepared in Dr. Ghannoum’s 
laboratory using an automated MicroLab STAR® system 
(Hamilton). Refer to the MOPS for details about specimen 
collection timing, tube type, required volume, and processing. 
 
6.3.5.5 Immunologic Studies 
 
CD4/CD8 T-cell counts will be done in real-time at screening, study entry 
and all post-entry study visits in a CLIA-certified or equivalent laboratory. 
 
CRP measurements will be performed in batch in the Lederman-Sieg 
laboratory using a commercial ELISA kit. Specimens for CRP testing will 
be collected at each visit, beginning with the study entry visit.  
 
PBMCs will be isolated and frozen according to the HANC Cross-Network 
Consensus Cryopreservation SOP and aliquoted at 5 to10x106 cells per 
vial in one ml. Refer to the MOPS for details of tube type, blood volume 
required and processing. PBMCs will be used for the following batched 
assays, all of which will be performed using standard flow cytometry 
techniques in the Lederman-Sieg laboratory:  
 
• 
CD4 and CD8 T cell maturation subset frequencies 
• 
Expression of CD127, bcl-2, α4β7, and Ki-67 on each CD4 and CD8 
subset 
• 
Ex vivo responsiveness of circulating T cells to IL-7 will be measured 
by Stat 5 phosphorylation and induction of α4β7 expression 
• 
Expression of the activation markers CD38 and HLA-DR on CD4 and 
CD8 T cells 
• 
Frequency of CD4 T cells expressing high levels of the coinhibitory 
molecule PD-1 
 
PBMCs will be also be used for the following real-time assays, all of 
which will be performed using standard flow cytometry techniques in the 
Lederman-Sieg laboratory: 
 
• 
Survival and ex vivo completion of cell division  by cycling cells by 
CFSE dye dilution within each T cell maturation subset 
• 
Monocyte subsets and tissue factor expression by flow cytometry 
 
 
On plasma, the following elements will be measured in batch from 
specimens obtained at the visit times outlined in section 6.1:  
 
• 
Bacterial LPS and its soluble receptor sCD14 
• 
Other inflammatory/coagulation markers (IL-6, IP-10, TNFrI, TNFrII, 
D-dimers) 
• 
Zonulin (reflective of gut barrier integrity) and intestinal fatty acid 
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6.3.5.6 Cardiovascular Studies (BART testing)  
 
Assessment of endothelial function will be done by flow-mediated dilatation 
(FMD), a measure of endothelium-dependent vasoreactivity obtained by brachial 
artery reactivity testing (BART). Hyperemic velocity time integral (VTI), also 
obtained during BART, is a complementary measure of microvascular health that 
may be more predictive of cardiovascular events than FMD.  Both indices will be 
measured in the UHCMC Harrington Heart and Vascular Institute.  BART will be 
performed at baseline and at the time of arm shift at week 20, as well as 2 weeks 
after the last dose in each of the study periods (weeks 10 and 30). Refer to the 
MOPS for further instructions. 
 
6.3.5.7 Sigmoidoscopy and Biopsies 
 
All subjects will be offered the opportunity to participate in the rectosigmoid 
specimen collection program, but consent to provide rectosigmoid biopsy 
specimens will not be a requirement to be on the main study. It is expected, 
based on previous experience at the UHCMC CRS that approximately 50% of 
the subjects will consent to flexible sigmoidoscopy and biopsies. Since 2011, the 
investigators have maintained an IRB-approved protocol to obtain rectosigmoid 
biopsies via flexible sigmoidoscopy from HIV-infected patients and normal 
volunteers at the UHCMC site. Since then, approximately 45 subjects have been 
approached for participation, of whom 25 (56%) consented. Thus, we do not 
anticipate difficulties recruiting subjects to participate in the rectosigmoid 
specimen collection part of the study.  
 
There are no published data on the effects of tocilizumab on GALT in HIV-
infected subjects. Therefore, while approximately 50% of the entire study 
population is expected to agree to participate in the gut sampling section of the 
study, even a smaller number of observations will provide valuable information, if 
the actual proportion of participants willing to undergo rectosigmoid biopsies is 
lower than anticipated. 
 
Procedures will be performed in the endoscopy suite of University Hospitals 
Case Medical Center at the visits specified in section 6. Subjects will receive 
instructions for preparation before the procedure as per established practice at 
the UHCMC Digestive Health Institute.  
 
Briefly, the procedure will include the following steps:  
 
• 
Subjects will be asked to fast after midnight on the evening before the 
procedure.  
• 
Subjects will be asked to self-administer two enemas 2 hours prior to the 
procedure 
• 
Visual and digital rectal exam: The examiner will conduct a visual 
examination of the anus and surrounding area and note any abnormality.  
The examiner will then insert a lubricated gloved finger into the anal canal 
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• 
Flexible sigmoidoscopy and biopsy: A flexible sigmoidoscope will be inserted 
to approximately 15 cm from the anal verge, in order to reach beyond the 
dentate line and minimize discomfort for the subjects, noting any lesions or 
abnormalities. Approximately 20 biopsies will be taken using disposable 
large-cup biopsy forceps. 
 
All procedures will be performed by a trained gastroenterologist and endoscopist 
in the endoscopy suite at the UHCMC Digestive Health Institute. Further 
instructions are provided in the MOPS.  
 
 
6.4 Specimen Collection, Handling, and Processing 
 
6.4.1  General Specimen Management Guidance 
 
The study site will adhere to the standards of good clinical laboratory practice, 
DAIDS Laboratory Requirements and site standard operating procedures for 
proper collection, processing, labeling, transport, and storage of specimens at 
the 
local 
laboratories, 
as 
described 
in 
(http://www.niaid.nih.gov/LabsAndResources/resources/DAIDSClinRsrch/Docum
ents/gclp.pdf)  
 
Specimen collection, testing, and storage at the site laboratories will be 
documented per standard site practice. In cases where laboratory results are not 
available due to administrative or laboratory error, specimens intended for use in 
the screening as well as ongoing safety assessments process may be re-drawn. 
 
6.4.2 Storage of Specimens for Future Use 
 
Study staff will store all specimens collected in this study on site at least through 
the end of the study. Specimens will not be labeled with any personal identifiers.  
Storage of all study samples will follow local standard operating procedure to 
ensure the anonymity and confidentiality of the trial research participants. 
Specimens remaining at the end of the study will be transferred to a designated 
bio-repository with appropriate participants’ permission and after all protocol-
required and quality assurance testing has been completed. If such permission is 
not obtained, those participant’s samples will be destroyed. 
 
Informed consent for storage of specimens for future studies will be obtained 
through an existing IRB-approved protocol that governs the existing bio-
repository at UHCMC. This protocol exists under the oversight of the Case 
Western Reserve University Center for AIDS Research (CFAR), and is one of the 
resources of the CFAR Clinical Services Core, which is directed by Dr. 
Rodriguez. The Clinical Services Core maintains a fully HIPAA-complaint 
repository management system, and the protocol provides for separate consents 
to use stored specimens for: a) use of deidentified data for research purposes; b) 
non-genetic studies; c) genetic studies; and d) authorization to contact 
participants for future studies. Participants can consent to any, all, or none of the 
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in real time, for each record in the database and for each specimen, whether a 
valid consent of any of the four types described above exists in the system.   
 
7.0 CLINICAL MANAGEMENT ISSUES 
 
If at any time, a decision is made to discontinue study agent in all participants, the IND 
Sponsor (Dr. Benigno Rodriguez), after consultation with the DAIDS MO, and the 
protocol team will inform the US Food and Drug Administration (FDA), the IRB, and the 
site investigators.  
 
The grading system for drug toxicities is located in the Division of AIDS (DAIDS) Table 
for Grading the Severity of Adult and Pediatric Adverse Events, Version 2.0, November 
2014, available at http://rsc.tech-res.com/safetyandpharmacovigilance.  
 
7.1 Management of Specific Adverse Events 
 
 
7.1.1 Serious Infections 
 
All subjects will be monitored for signs or symptoms of a serious or local infection 
at each visit. All subjects who develop a serious infection while on study will be 
referred for immediate medical care to a qualified healthcare professional, and 
will be required to discontinue study treatment, as specified below. Instructions 
for evaluations in subjects who discontinue study treatment are provided in 
section 6.2.17.3. 
 
 
• 
Participants who develop any infection listed in section 8.1 will 
discontinue study treatment permanently. 
• 
Participants who experience an infection that is considered life-
threatening or that requires inpatient treatment, will discontinue study 
treatment permanently.  
• 
Subjects who experience other serious infections not listed in 8.1 and 
that do not require inpatient treatment and are not considered life-
threatening will have study treatment temporarily stopped until the 
infection is controlled.  These subjects may restart study drug once the 
infection is controlled. 
 
Other infections, including local infections, will also require referral to qualified 
medical treatment, and all of them will also require, at a minimum, temporary 
discontinuation of study treatment until the infection is adequately controlled. The 
study co-chairs, in consultation with the Medical Officer, will determine if an 
infection not listed in section 8.1 warrants permanent treatment discontinuation 
even after the infection has been adequately controlled. 
 
7.1.2 Acute Hypersensitivity Reactions 
 
To minimize the risk of a severe, immediate-type hypersensitivity reaction, all 
doses of study agent will be administered in the Dahms Clinical Research Unit, 
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inpatient management capabilities, including the ability to provide Advanced 
Cardiac Life Support and to transfer a patient to an intensive care bed without 
leaving the building complex. Full resuscitation equipment is available within the 
DCRU, and personnel trained in the management of anaphylaxis are available 24 
hours a day.  
 
Development of a grade ≥3 hypersensitivity reaction OR a grade 2 
hypersensitivity reaction that includes manifestations of angioedema will require 
permanent treatment discontinuation.  
 
 
7.1.3 Gastrointestinal Perforation 
 
All subjects will be monitored for signs or symptoms of gastrointestinal 
perforation at each visit. Subjects who present with new onset of abdominal 
symptoms will be immediately referred for immediate evaluation by a qualified 
healthcare professional to rule out gastrointestinal perforation. Subjects who 
develop a gastrointestinal perforation during study will be required to discontinue 
study treatment permanently, and will be followed until resolution of the AE.  
 
 
7.1.4 Infusion Reactions 
 
To minimize the risk of severe infusion reactions, all doses of study agent will be 
administered in the Dahms Clinical Research Unit, which is located within the 
Rainbow Babies & Children’s Hospitals and has full inpatients management 
capabilities, including the ability to provide Advanced Cardiac Life Support and to 
transfer a patient to an intensive care bed without leaving the building complex. 
Full resuscitation equipment is available within the DCRU, and personnel trained 
in the management of infusion reactions are available 24 hours a day.  
 
Development of a grade ≥3 infusion reaction will require permanent treatment 
discontinuation. 
 
7.1.5 Laboratory Abnormalities 
 
7.1.5.1 Neutropenia 
 
A CBC with differential will be obtained at each study visit from entry to 
end of study. Subjects who develop neutropenia will be referred for 
treatment by a qualified healthcare professional. Subjects with an ANC 
<2,000 cells/mm3 at screening will be excluded.  
 
Subjects who develop an ANC ≤1,000 but ≥500 cells/mm3 will be required 
to discontinue study treatment temporarily for the visit at which the low 
ANC was recorded, and the pharmacy will be notified to provide a 4 
mg/Kg dose of the assigned study agent, regardless of scheduled dose, 
until the ANC has risen to above 1,000 cells/mm3. Unblinding will not be 
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Subjects who develop an ANC ˂500 cells/mm3 will be required to 
discontinue study treatment permanently.  
 
7.1.5.2 Thrombocytopenia 
 
A platelet count will be obtained at each study visit from enrollment to end 
of study. Subjects who develop thrombocytopenia will be referred for 
treatment by a qualified healthcare professional. Subjects with a platelet 
count below 100,000 cells/mm3 at screening will be excluded.  
 
Subjects who develop a platelet count ≤100, 000 but ≥50,000 cells/mm3 
will be required to temporarily discontinue study treatment for the visit at 
which the low platelet count was recorded, and the pharmacy will be 
notified to provide a 4 mg/Kg dose of the assigned study agent, 
regardless of scheduled dose. The 4 mg/Kg dose will be continued until 
the platelet count has risen to above 100,000 cells/mm3. Unblinding will 
not be required.  
 
Subjects who develop a platelet count ˂50,000 cells/mm3 will be required 
to discontinue study treatment permanently. 
 
7.1.5.3 AST and ALT Abnormalities 
 
AST and ALT will be monitored at each visit from study entry to the end of 
study. Subjects with AST or ALT over 1.5 times the upper limit of normal 
or who have evidence of hepatitis B or hepatitis C at screening will be 
excluded.  
 
7.1.5.3.1 AST or ALT >1.4 to 3 Times the Upper Limit of Normal 
 
Subjects who develop an AST or ALT in this range while on 
study may continue study treatment, but the pharmacy will be 
notified to provide a dose of 4 mg/Kg of the assigned study 
agent, regardless of the scheduled dose. Unblinding will not be 
required. The dose will not be increased to 8 mg/Kg until both 
the AST and ALT have returned to below the upper limit of 
normal.  
 
 7.1.5.3.2 AST or ALT ˃3 to 5 Times the Upper Limit of Normal 
 
Subjects who develop an AST or ALT in this range will 
temporarily discontinue study treatment, until both the AST 
and ALT return to below 3 times the upper limit of normal, at 
which time guidelines outlined in section 7.1.5.3.1 will apply. 
Unblinding will not be required.  
 
 


 
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 7.1.5.3.3 Liver Enzymes ˃5 Times the Upper Limit of Normal 
 
Subjects who develop an AST or ALT in this range will be 
required to discontinue study treatment permanently.  
 
 
7.1.5.4 Lipid Abnormalities 
 
Subjects who experience incident lipid abnormalities will be referred for 
adequate medical treatment by a qualified healthcare professional, but in 
light of the short duration of the study, isolated lipid abnormalities will not 
require study treatment modification or discontinuation. In general, 
treatment for dyslipidemias by providers in the John T. Carey Special 
Immunology Unit of UHCMC follows the ATP III guidelines. Consultation 
with experts in cardiovascular risk is available on-site in the Special 
Immunology Unit by co-investigator Dr. Chris Longenecker.  
 
 
7.1.6 Malignant Conditions 
 
All subjects will be monitored for signs or symptoms of a malignant condition at 
each visit. Subjects who develop a malignancy other than a basal cell skin 
carcinoma requiring no more than local excision during study will be required to 
discontinue study treatment permanently.  
 
7.1.7 Viral Reactivation 
 
Subjects who develop pain, a skin rash, or other clinical manifestation deemed 
consistent with an episode of herpes zoster, will be immediately referred for 
evaluation by a qualified clinician, and will be required to discontinue study 
treatment until any pharmacologic treatment for varicella-zoster has been 
completed and the clinical manifestations have resolved in the judgment of the 
treating physician. Subjects who develop recurrence of signs or symptoms or 
herpes zoster reactivation, and those who develop involvement of more than two 
dermatomes or have evidence of visceral involvement while on study will be 
require to discontinue study treatment permanently.   
 
Subjects who develop a detectable HBV DNA at any time during the study will be 
required to discontinue study treatment permanently, and will be referred for 
specialized medical care a soon as the study team becomes aware of a positive 
HBV DNA result.  
 
7.1.8 Cytochrome P450 Inhibition and Decreased Plasma Levels of Antiretrovirals 
 
If a trough level of an antiretroviral agent that is part of a subject’s regimen is 
reported to be below the cutoff levels listed in table 2 (section 4.2.16), a 
confirmation visit will be scheduled as soon as the result is received. The 
confirmation visit must occur within 5 weeks of the initial specimen collection date 
(due to an expected turnaround time of 2-3 weeks for the antiretroviral level 
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treating physician will be informed of the result, as well as the confirmatory test 
result when available.  
 
The results of the plasma HIV RNA must also be reviewed each time an 
antiretroviral level test is below the cutoff. If the concomitant plasma HIV RNA 
level is below the limit of detection of the assay, subjects will be allowed to 
continue study treatment until the confirmation test result is obtained.  
 
If the plasma HIV RNA corresponding to the initial low antiretroviral level result is 
above the limit of detection of the assay, the subject will be required to 
discontinue study treatment temporarily until the confirmatory result is available, 
and a confirmatory virologic failure blood draw will be scheduled. If the 
confirmation antiretroviral level result is also below the cutoff level, the subject 
will be required to discontinue study treatment permanently.  
 
 
7.1.9 Demyelinating Conditions  
 
All subjects will be monitored for signs or symptoms of a demyelinating condition 
at each visit. Subjects who develop a demyelinating condition such as multiple 
sclerosis or chronic inflammatory demyelinating polyneuropathy during study will 
be required to discontinue study treatment permanently.  
 
 
7.2 Management of Other Adverse Events  
 
7.2.1 Grade 1 or 2 AE 
 
Subjects who develop a Grade 1 or 2 AE other than those discussed in Section 
7.1 may continue study treatment.  
 
7.2.2 Grade 3 AE 
 
If the investigators have compelling evidence that the AE has NOT been caused 
by the study treatment, dosing may continue. Otherwise, subjects who develop a 
Grade 3 AE will have study treatment withheld, except as stated in section 7.1. 
The subject will be reevaluated closely until the AE returns to Grade ≤2, at which 
time study treatment may be reintroduced at the discretion of the investigators or 
according to standard practice.  
 
If the same Grade 3 AE recurs during the study, study treatment must be 
permanently discontinued unless an alternative etiology for the AE that is not 
related to study treatment has been identified.  
 
Subjects experiencing Grade 3 AEs requiring permanent discontinuation of study 
treatment will be followed closely for resolution of the AE to Grade ≤ 2 and the 
protocol core team will be notified. 
 
 
 


 
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7.2.3 Grade 4 AE 
 
Subjects who develop a Grade 4 symptomatic AE will have study treatment 
discontinued. If the investigators have compelling evidence that the AE has NOT 
been caused by the study treatment, after consultation with the safety monitoring 
committee (SMC, refer to section 9.4) and the DAIDS MO, dosing may resume 
when the AE has resolved. Subjects experiencing Grade 4 AEs requiring 
permanent discontinuation of study treatment will be followed closely until 
resolution of the AE to Grade ≤ 2 and the protocol core team will be notified. 
 
7.3 Resumption of Study Treatment Administration when the Crossover Dose Is Held 
 
If the first dose of the second period (week 20) is held for any of the reasons described 
above, the first dose given at a subsequent visit will always be 4 mg/Kg.  
  
7.4 Pregnancy  
 
All women of reproductive potential will be asked to affirm that they currently use and will 
continue to use throughout the study two different methods of contraception as specified 
in section 4.1.11. At each visit, continued use of acceptable contraceptive methods will 
be ascertained and recorded in the source documents. Additionally, on each of the study 
dosing visits, women of childbearing potential will be required to undergo rapid 
pregnancy testing. Both the ascertainment of continued use of acceptable contraceptive 
methods and verification of a negative pregnancy test will be done before administering 
the study medication. Women who have interrupted one or both contraceptive methods 
will discontinue study treatment until they have resumed use of acceptable contraceptive 
methods.  
 
Female subjects who become pregnant while on study treatment despite the above 
measures must immediately discontinue study treatment and consult with their primary 
healthcare providers. In consultation with the subject, her healthcare provider, and the 
SMC, a decision may be made to unblind the participant if she requests access to 
unblinding information to assist in her decision making process about the pregnancy. 
Subjects will be encouraged to remain in the study to be followed on study/off study 
treatment until study completion and will be followed by telephone contact thereafter to 
determine the pregnancy outcome. Pregnant women will also be invited to enroll in the 
pregnancy registry by calling 1-877-311-8972. Pregnancy-related outcomes (health of 
the infant) and any pregnancy-related complications (e.g., fetal loss/abnormalities) must 
be reported on the CRF. Subjects should have the premature treatment discontinuation 
evaluations completed within 2 weeks after stopping study treatment.  
 
NOTE:  Pregnant subjects will be considered on study until the outcome of the 
pregnancy has been obtained and reported on the CRF.  
 
7.5 Reporting of Adverse Reactions to the Responsible IRBs 
 
The investigators will report adverse reactions to the responsible IRB in accordance with 
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Follow-up information to a reported adverse event will be submitted to the IRB as soon 
as the relevant information is available.  If the results of the investigator’s follow-up 
investigation show that an adverse event that was initially determined to not require 
reporting to the IRB does, in fact, meet the requirements for reporting, the investigator 
will report it as soon as possible in accordance with respective IRB policies and 
procedures. 
 
7.6 Social Harms Reporting 
 
Although the study site makes every effort to protect participant privacy and 
confidentiality, it is possible that participants' involvement in the study could become 
known to others, and that social harms may result (i.e., because participants could 
become known as HIV-infected). For example, participants could be treated unfairly or 
discriminated against, or could have problems being accepted by their families and/or 
communities. 
 
Social harms that are judged by the study chairs to be serious or unexpected will be 
reported to responsible site IRB at least annually or according to their individual 
requirements. In the event that a participant reports social harm, every effort will be 
made by study staff to provide appropriate care and counseling to the participant, and/or 
referral to appropriate resources for the safety of the participant as needed.   
 
8.0 CRITERIA FOR DISCONTINUATION 
 
8.1 Permanent Treatment Discontinuation 
 
• 
Interruption of antiretroviral medications for ˃4 consecutive weeks 
• 
Change of antiretroviral medications to a regimen that does not meet the criteria for 
eligible antiretroviral treatment in section 4.1.6 for ˃4 consecutive weeks.   
• 
Loss of virologic control, defined as a plasma HIV RNA ˃200 copies/mL on two 
consecutive occasions at least two weeks apart. A single plasma HIV RNA 
measurement ˃200 copies/mL is permissible if the subsequent measurement is ˂200 
copies/mL. 
• 
Occurrence of a grade ≥3 hypersensitivity reaction or infusion reaction OR a grade 2 
hypersensitivity reaction that includes angioedema of any grade 
• 
Drug-related AE meeting the criteria for discontinuation in sections 7.1 or 7.2. 
• 
Occurrence of any of the following opportunistic complications:  
 
o Tuberculosis, pulmonary or extrapulmonary 
o Non-tuberculous mycobacterial infection, disseminated or extrapulmonary 
o Pneumocystis jirovecii pneumonia 
o Coccidioidomycosis, disseminated or extrapulmonary 
o Cryptococcosis, extrapulmonary 
o Cryptosporidiosis or isosporiasis, chronic intestinal (greater than 1 month's 
duration) 
o Cytomegalovirus disease (other than liver, spleen, or lymph nodes) and including 
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o Histoplasmosis, disseminated or extrapulmonary 
o Kaposi's sarcoma 
o Lymphoma, Burkitt's or immunoblastic, regardless of anatomical location 
o Lymphoma, primary of brain 
o Progressive multifocal leukoencephalopathy 
o Toxoplasmosis of brain 
 
• 
Occurrence of herpes zoster reactivation involving more than one dermatome or 
visceral involvement including but not limited to viral pneumonia, encephalitis and 
hepatitis. 
• 
Recurrence of herpes zoster reactivation while on study, regardless of anatomic 
location.  
• 
Development of a detectable HBV DNA at any time during the study. 
• 
Occurrence of a serious infection that is considered life-threatening or requires 
inpatient treatment.  
• 
Occurrence of an incident cancer other than a localized basal cell carcinoma of the 
skin that requires local excision only 
• 
Occurrence of a suspected or confirmed demyelinating condition.  
• 
Occurrence of an AST or ALT level above 5 times the upper limit of normal. 
• 
Occurrence of an ANC below 500 cells/mm3. 
• 
Occurrence of a platelet count below 50,000 cells/mm3. 
• 
Requirement for prohibited concomitant medications (see appendix 1 of the MOPS). 
• 
A confirmed trough level of a protease inhibitor or non-nucleoside reverse 
transcriptase inhibitor included in the subject’s antiretroviral regimen that is lower 
than the lower limit of the steady-state trough level range observed in published 
studies. Refer to section 4.2.16 for cutoff values.  
 
 
NOTE: For the purposes of this treatment discontinuation criterion, “confirmed” refers 
to two consecutive trough levels of the antiretroviral agent no more than 5 weeks 
apart that are both below the expected level, as defined in  section 4.2.16.  
 
• 
Pregnancy or breastfeeding. 
• 
Completion of treatment as defined in the protocol. 
• 
Request by subject to terminate treatment. 
• 
Reasons believed to be clinically significant by the investigators, even if not 
addressed in the adverse event management section of the protocol. 
 
8.2 Premature Study Discontinuation 
 
• 
Failure by the subject to attend 3 consecutive visits or 2 medication visits during the 
study defined study windows. 
• 
Request by the subject to withdraw. 
• 
Request of the primary care provider if s/he thinks the study is no longer in the best 
interest of the subject. 
• 
Subject judged by the investigator to be at significant risk of failing to comply with the 
provisions of the protocol as to cause harm to self or seriously interfere with the 
validity of the study results. 
• 
At the discretion of the institutional review board (IRB), Office for Human Research 
Protections (OHRP), FDA, NIAID or investigator.  


 
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8.3 Temporary Treatment Discontinuation 
  
• 
Subjects who meet a temporary treatment discontinuation criterion (sections 7.1 and 
7.2) will be required to discontinue study treatment temporarily.  
• 
If a subject has not received any component of his/her antiretroviral treatment for ≥72 
hours prior to a scheduled treatment administration visit, study treatment will be held 
for that visit, and this treatment modification will be recorded on the CRF. Study 
treatment administration can resume once the subject has received continuous 
antiretroviral treatment (without interruption ≥72 hours) for at least 28 days.   
• 
Interruption of contraceptive methods in a female participant of reproductive potential 
such that at any time, the participant is using fewer than two methods as detailed in 
section 4.1.11. Study treatment administration can resume once the participant has 
been receiving an acceptable contraceptive regimen for at least 30 days. 
 
8.4 Criteria for Unblinding 
 
The SMC, in consultation with the statistician, will determine whether unblinding of a 
subject’s arm assignment is warranted, and which personnel must receive the unblinding 
information. Regardless of determination, the decision will be reported to both the 
DAIDS MO and the FDA, in addition to any additional reporting requirements related to 
the event precipitating the unblinding. Unblinding will be considered in the following 
cases:  
 
• 
Pregnancy 
• 
Occurrence of a life-threatening adverse event that is thought to be probably or 
definitely related to study treatment 
• 
Occurrence of a number of AEs that meets criteria for study discontinuation, 
where ascertainment of arm assignment is needed to establish relationship to 
TCZ (see section 12.3).  
• 
Emergence of a concomitant medical condition that requires knowledge of the 
study agent administered for optimal medical management 
• 
Upon instructions from the FDA, DAIDS, OHRP, or IRB 
 
9.0 STATISTICAL CONSIDERATIONS 
 
9.1 Design and Primary Endpoints 
 
 
This is a randomized, double-blind crossover (AB/BA) study. The data analysis will 
evaluate the effect of TCZ on safety, inflammation, cellular cycling, and various 
secondary endpoints. The analysis of all secondary endpoints will be exploratory only. 
The primary endpoints are described below.  
 
9.1.1 Primary Endpoint 1 (Safety) 
 
The primary safety endpoint is the frequency of grade ≥2 clinical or laboratory 
adverse events related to study treatment during each period. 
 
 


 
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9.1.2 Primary Endpoint 2 (Inflammation) 
 
The primary inflammation endpoint is serum C-reactive protein level at 10 weeks 
and 30 weeks. 
 
9.1.3 Primary Endpoint 3 (Cellular Cycling) 
 
The primary cellular cycling endpoint is the proportion of central memory T cells 
expressing the nuclear antigen Ki67 at 10 weeks and 30 weeks. 
 
9.2 Statistical Analysis 
 
All data analyses will be performed in the intent to treat population and will analyze 
subjects using the sequence to which they were randomly assigned. Additionally, a 
planned secondary analysis will be conducted that will include only subjects who 
completed study treatment and were followed up to week 30 at a minimum. Because it is 
desired to obtain a sufficient level of precision for both the primary (intention-to-treat) 
and the secondary (complete observation) analyses, the sample size and power 
calculations are based on the expected number of subjects who will have complete 
follow-up data (thirty subjects out of up to 36 enrolled subjects). 
 
9.2.1. Baseline Comparability 
 
To examine subject differences between the two sequences, variables measured 
prior to treatment initiation in the first period as well as the within-subject 
treatment effect on each primary and secondary endpoint (defined by the 
differences in endpoints between week 10 and week 30) will be summarized by 
sequence using standard summary statistics and subject-profile plots as 
necessary. Similarly, to examine differences between the two periods, within-
subject differences in each endpoint between study entry and week 10 (or week 
20 and week 30) will be summarized by group (tocilizumab or placebo) and 
period. The approach is the same for cardiovascular values and for rectal tissue 
studies, EXCEPT for those endpoints, all changes will be measured relative to 
the baseline visit (visit 2).  
 
9.2.2 Safety Analysis 
 
Safety will be assessed in all participants who are randomized and begin study 
treatment. The number and percentage of participants experiencing at least one 
grade ≥2 clinical or laboratory adverse event related to study treatment during 
each period (0 to 10 weeks for Period 1 or 20 to 30 weeks for Period 2) will be 
tabulated separately for each treatment arm. Based on the Clopper-Pearson (98) 
method, an exact 95% confidence interval of the probability of a safety event will 
be estimated separately for each arm. 
 
9.2.3 Primary Analysis of Two Co-Primary Endpoints 
 
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and begin study treatment. To test the null hypothesis that the mean of each co-
primary endpoint is the same in both arms, a separate linear mixed model will be 
used to estimate the mean (and 95% CI) of the difference in each endpoint 
between treatment arms, adjusting for period. To increase the precision of the 
estimated treatment effect, the within-period baseline measurements of each 
endpoint will be included as responses in the linear mixed model using the 
method described in Kenward and Roger (99). If all subjects complete all visits, 
such an analysis will provide estimates of the treatment effect that are identical to 
an analysis using within-period baseline measurements as covariates.  
 
9.2.4 Secondary Safety Analyses  
 
To test the null hypothesis that the incidence of safety events is the same during 
treatment with TCZ as during treatment with placebo (versus the alternative 
hypothesis that the incidence of safety events is not the same during TCZ 
treatment as during placebo treatment), an estimate, 95% CI, and p-value of the 
relative risk of a safety event (TCZ: placebo) will also be calculated using a 
generalized linear mixed model that is estimated via Gaussian quadrature. The 
model will be based on a binomial distribution with a log link function and will 
incorporate fixed effects for period and treatment as well as a random effect 
representing subjects within sequence.  
 
Secondary analyses using the number of grade ≥2 clinical or laboratory adverse 
events related to study treatment during each period (0 to 10 weeks for Period 1 
or 20 to 30 weeks for Period 2) will also be performed. To test the null hypothesis 
that the rate of such events is the same during TCZ as during placebo treatment 
(versus the alternative hypothesis that the rate of these events is not the same 
during TCZ as during placebo treatment), the relative rate of a safety event (TCZ: 
placebo) will be estimated using a generalized linear mixed model based on a 
Poisson distribution and an offset variable to account for varying follow-up times 
within each period (which may arise due to study discontinuation). Fixed and 
random effects in the model will remain the same as previously described. 
 
9.2.5 Secondary Analyses of Two Co-Primary Endpoints 
 
The primary analysis of the two co-primary (CRP and T cell cycling) endpoints 
will specifically focus on the changes from study entry to week 10 and from week 
20 to week 30. However, some endpoints are measured at other time points as 
well (see Table 6.1) and so to estimate the treatment effect at these time points, 
a secondary analysis will be done by fitting the model defined in Kenward and 
Roger (99) to include these additional measurements. 
 
 
9.2.6 Adjustment for Baseline Covariates Measured prior to Randomization  
 
In the case of a cross-over study with complete data, adjustment for baseline 
covariates measured prior to randomization has no effect on estimates of the 
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within-subject difference. However, this property does not hold if any endpoint 
data on a subject is missing. Because we expect some participants will drop-out 
of the study before the 30 week timepoint, secondary analyses will be conducted 
that incorporate fixed effects for CD4 T cell count, type of ART, and time since 
HIV diagnosis into the mixed models previously described.  
 
9.2.7 Carry-over Effects 
 
An important consideration in any cross-over design is the existence of a carry-
over effect. In the past, a formal test for a carry-over effect was done using a test 
of the interaction between treatment arm and period and if one was detected, an 
analysis of Period 1 data was performed. However, as discussed by Senn (100), 
this type of sequential strategy is not very useful because many cross-over 
designs are underpowered to detect such interactions and even if one is 
detected, tests based on Period 1 data are also underpowered. With this in mind, 
no formal test for a carry-over effect will be conducted. Instead, a 12 week 
washout period (over 10 times the half-life of tocilizumab) has been incorporated 
into the study design to account for a possible carryover effect.  
 
9.2.8 Multiplicity 
 
There are 3 co-primary endpoints in this study: safety, CRP, and T cell cycling. 
The primary analysis for the safety endpoint is based on an estimate of precision, 
rather than a formal hypothesis test, because the rate of adverse events is 
expected to be low and the sample size is too small to detect any clinically 
meaningful differences between the two arms. Consequently, adjustment for 
multiplicity will only be done for the two co-primary endpoints, CRP and T cell 
cycling using a Bonferroni-Holm’s method. This method will ensure that the 
familywise error rate (e.g., the probability of at least one Type I error arising from 
the two tests) does not exceed 0.05.  
 
Note that all secondary objectives are exploratory and so no adjustment will be 
made to account for inflation of the Type I error rate arising from hypothesis tests 
of the secondary endpoints. Any results from these endpoints will be considered 
hypothesis-generating and will require further confirmation and replication to be 
considered established.  
 
9.2.9 Missing Data 
 
While simpler statistical methods could have been chosen to test our null 
hypotheses (e.g., a matched pairs t-test to compare the mean of continuous 
endpoints between arms; a McNemar’s test to compare the proportion of safety 
events between arms), these methods remove subjects with any missing 
endpoint data from the entire analysis and assume that the mechanism for 
missing data is completely at random (e.g., subjects with complete data are a 
random sample of subjects from the study population). Because this assumption 
does not typically hold, a maximum likelihood approach based on generalized 
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having an endpoint measured on at least one time point and produces unbiased 
parameter estimates when response data is missing at random (e.g., the missing 
data mechanism depends only on observed, not unobserved responses).  
 
9.3 Sample Size Justification 
 
9.3.1 Sample Size Considerations for Safety 
 
Published TCZ safety studies have not used the DAIDS AE grading system, and 
therefore specific estimates of the expected frequency of grade ≥2 AEs are not 
available. Nonetheless, in the integrated database, the frequency of AEs 
requiring study discontinuation was 6.9/100 PY in the placebo group and 10.2 in 
the TCZ 8 mg/Kg group (67). The follow-up time in each period is 10 weeks and 
so assuming similar frequencies of adverse events occur, we expect to observe 
zero or one event in each arm among 30 subjects. 
 
A single summary outcome of this type (yes/no) can be assumed to follow a 
Bernoulli distribution. Consequently, Table 19 shows the probability of zero, one 
or more, two or more, and three or more subjects experiencing a qualifying AE in 
each arm in a sample of 30 subjects with complete follow-up data through week 
30. Selected true underlying probabilities of at least one grade ≥2 clinical or 
laboratory adverse event related to study treatment vary between 0.01 and 0.10. 
Table 20 shows the exact 95% confidence intervals for the probability of a 
qualifying event in each arm when 0 to 5 events are observed among 30 subjects 
with complete follow-up data through week 30. 
  
Table 19. Probability of events for selected true probabilities of qualifying AEs 
True rate 
Zero subjects 
One or more 
subjects 
Two or more 
subjects 
Three or more 
subjects 
0.01 
0.74 
0.26 
0.036 
0.0033 
0.02 
0.55 
0.45 
0.12 
0.022 
0.03 
0.4 
0.6 
0.23 
0.06 
0.04 
0.29 
0.71 
0.34 
0.12 
0.05 
0.21 
0.79 
0.45 
0.19 
0.06 
0.16 
0.84 
0.54 
0.27 
0.07 
0.11 
0.89 
0.63 
0.35 
0.08 
0.082 
0.92 
0.7 
0.43 
0.09 
0.059 
0.94 
0.77 
0.51 
0.1 
0.042 
0.96 
0.82 
0.59 
 
9.3.2 Sample Size Considerations for Inflammation and Cellular Cycling  
 
In the 8 mg/kg arm of a tocilizumab registrational trial, CRP decreased from 
2.8±3.37 to approximately 0.5 mg/dL mg/dL at week 12 (101). Although there are 
no published data on the effect of TCZ on T cell cycling, in our CLIF study, 
5.18±2.54% of central memory CD4 T cells were in cycle among immune failure 
subjects compared to 2.91±1.03 among immune success subjects(6). 


 
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Table 20. Exact 95% CIs for probability of a qualifying AE  
Observed number 
of events 
Estimated 
probability 
Lower bound 
Upper bound 
0 
0 
0 
0.12 
1 
0.033 
0 
0.17 
2 
0.067 
0.0082 
0.22 
3 
0.1 
0.021 
0.27 
4 
0.13 
0.038 
0.31 
5 
0.17 
0.056 
0.35 
 
While this value is not related to the administration of TCZ, we will use this 
difference as a plausible observable difference because both immune failure and 
immune success subjects in the CLIF study were virologically controlled subjects, 
similar to those who will be included in the present study who were not receiving 
an immunomodulatory agent. 
 
Under these assumptions, power calculations were performed under a variety of 
scenarios. In particular, we assumed that the within-subject mean difference 
between TCZ and placebo arms in CRP and T cell cycling would vary between 2 
and 3 units, the standard deviation in CRP in either arm would vary between 3 
and 4, the standard deviation in T cell cycling in either arm would vary between 1 
and 3, the correlation between the first and second period measurements for 
either endpoint would vary between 0.2 and 0.5, and no carryover effect. Under 
these assumptions, we then conducted 5000 simulations to estimate empirical 
power. For each simulation, data for 30 subjects was simulated, a paired t-test 
was applied to each endpoint, and the p-values were adjusted using Holm’s 
method to ensure that the familywise-error rate arising from the two tests was 
maintained at 0.05. We then calculated the empirical power for: 1) Detecting the 
specified mean difference in CRP between the 2 arms; 2) Detecting the specified 
mean difference in T cell cycling between the 2 arms; 3) Detecting the specified 
mean difference in CRP or T cell cycling between the 2 arms (any pair power); 
and 4) Detecting the specified mean difference in both CRP and T cell cycling 
between the 2 arms (all pair power). The results are provided in Table 21 and 
show that, assuming a sample size of 30 subjects with complete follow-up 
through week 30, there is ample power to detect the hypothesized mean 
difference in T cell cycling between TCZ and placebo arms in the vast majority of 
scenarios and adequate power to detect the hypothesized mean difference in T 
cell cycling between TCZ and placebo arms in most scenarios. 
 
9.3.3 Accrual and Loss to Follow-up 
 
Given the intensive nature of the study, losses to follow-up and premature 
treatment or study discontinuations are possible. An additional subject will be 
recruited for every subject who is lost to follow-up or discontinues study or study 
treatment before week 30, until up to 36 subjects total have been enrolled. Based 
on previous experience at the site, we estimate that this will yield approximately 
30 subjects with complete follow-up through week 30.  
 


 
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Table 21. Empirical power to detect mean differences in CRP and T cell cycling 
Mean 
difference 
in CRP 
Mean 
difference 
in T cell 
cycling 
SD 
in 
CRP 
SD in T 
cell 
cycling 
Correlation 
between first 
and second 
period 
measurements 
Power to 
detect 
mean 
difference 
in CRP 
Power to 
detect mean 
difference in 
T cell 
cycling 
Any 
pair 
power 
All 
pair 
power 
2 
2 
3 
1 
0.2 
0.79 
1 
1 
0.79 
0.5 
0.94 
1 
1 
0.94 
3 
0.2 
0.77 
0.77 
0.91 
0.63 
0.5 
0.93 
0.93 
0.99 
0.87 
4 
1 
0.2 
0.55 
1 
1 
0.55 
0.5 
0.75 
1 
1 
0.75 
3 
0.2 
0.53 
0.74 
0.83 
0.44 
0.5 
0.74 
0.93 
0.96 
0.7 
3 
3 
1 
0.2 
0.8 
1 
1 
0.8 
0.5 
0.94 
1 
1 
0.94 
3 
0.2 
0.8 
0.98 
0.99 
0.79 
0.5 
0.95 
1 
1 
0.95 
4 
1 
0.2 
0.55 
1 
1 
0.55 
0.5 
0.75 
1 
1 
0.75 
3 
0.2 
0.54 
0.98 
0.98 
0.54 
0.5 
0.76 
1 
1 
0.76 
3 
2 
3 
1 
0.2 
0.99 
1 
1 
0.99 
0.5 
1 
1 
1 
1 
3 
0.2 
0.98 
0.79 
0.99 
0.78 
0.5 
1 
0.94 
1 
0.94 
4 
1 
0.2 
0.88 
1 
1 
0.88 
0.5 
0.98 
1 
1 
0.98 
3 
0.2 
0.86 
0.78 
0.94 
0.7 
0.5 
0.97 
0.94 
1 
0.92 
3 
3 
1 
0.2 
0.99 
1 
1 
0.99 
0.5 
1 
1 
1 
1 
3 
0.2 
0.99 
0.99 
1 
0.98 
0.5 
1 
1 
1 
1 
4 
1 
0.2 
0.88 
1 
1 
0.88 
0.5 
0.98 
1 
1 
0.98 
3 
0.2 
0.88 
0.98 
0.99 
0.87 
0.5 
0.98 
1 
1 
0.98 
 
9.4 Monitoring 
 
 
The study data manager and statistician will prepare a monthly report of accrual, early 
study treatment and study discontinuations (and related reasons), baseline 
characteristics, Grade ≥2 signs and symptoms, Grade ≥2 laboratory abnormalities and 
reported serious adverse events (SAEs). Tables in the report will be based on the entire 
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treatment arm. This report will be reviewed by the research team and DAIDS Medical 
Officer on a monthly basis.  
 
The study data manager and statistician will also prepare a similar report on a quarterly 
basis for review by the DAIDS Medical Officer or designee. In this case, tables in the 
report will be stratified by treatment arm using a label of A and B to maintain blinding.  
 
Approximately 3 months after enrollment of the first subject and every 3 months 
thereafter, interim reviews of the study will occur. A Safety Monitoring Committee (SMC) 
will review reports similar to those described for the DAIDS Medical Officer but the 
reports will also include a summary of longitudinal changes in CD4 T-cell count and HIV-
1 RNA levels as well as the availability of stored samples for planned assays. 
 
In addition to the regularly scheduled reviews, the SMC will perform expedited reviews of 
the safety data, unblinded to treatment assignment, whenever any of the following 
happens:  
 
• 
Three or more participants have experienced a grade 3 AE that is deemed 
possibly, probably, or definitely related to study treatment 
• 
Two or more participants have experienced a grade 4 AE that is deemed 
possibly, probably, or definitely related to study treatment 
• 
Any death occurs on study that is deemed possibly, probably, or definitely related 
to study treatment 
 
Whenever any of the events above occurs, enrollment into the study will be paused until 
the SMC review has taken place and a determination has been made that enrollment 
can resume.  
 
The SMC will be composed of an investigator affiliated with Case Western Reserve 
University in a department other than the Division of Infectious Diseases and HIV 
Medicine, an investigator not affiliated with Case Western Reserve University, a 
biostatistician not connected to the trial, and a representative of the community or 
bioethicist. In addition to reviewing the monthly reports and all SAEs and EAEs, the SMC 
will meet every 3 months on a regular schedule, and every time a reason is identified by 
the DAIDS Medical Officer, study chairs, or study statisticians in consultation with the 
team. 
 
The DAIDS Medical Officer and DAIDS Program Officer will receive the following safety-
related documents sent to the FDA at the time they are reported to the FDA or earlier: all 
SAE reports, study drug-related AE reports expected or not, and a quarterly listing of all 
AEs. The DAIDS Medical Officer and DAIDS Program Officer will also receive copies of 
any correspondence received from the FDA. 
 
10.0 PHARMACOLOGY PLAN 
 
As discussed above, trough levels of antiretrovirals will be measured at the following 
visits: screening, study entry, week 4, week 8, week 10, week 20, week 24, week 28, 
and week 30, as well as premature study discontinuation or when needed for 


 
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confirmation of a possible pharmacologic interaction. Levels of TCZ will be measured in 
batch at the end of the follow-up period. Refer to section 4.2.16 for cutoff values for 
trough NNRTI and protease inhibitor levels. Confirmed trough levels below the cutoff 
values (found to be persistently below the threshold within 5 weeks of the initial 
measurement) will require study treatment discontinuation (refer to section 8.1).   
 
11.0 DATA COLLECTION AND MONITORING AND ADVERSE EVENT REPORTING 
 
11.1 Records to Be Kept 
 
CRFs will be provided for each subject. Subjects will not be identified by name on any 
CRFs. Subjects will be identified by the patient identification number (PID). Source 
documents and data will be maintained in accordance with Requirements for Source 
Documentation 
in 
DAIDS 
Funded 
and/or 
Sponsored 
Clinical 
Trials 
(http://www.niaid.nih.gov/LabsAndResources/resources/DAIDSClinRsrch/Documents/so
urcedocpolicy.pdf).  
 
Study personnel will maintain and securely store complete, accurate, and current study 
records throughout the study. Per US regulations, for each of the investigational 
products tested, the investigators will retain all study records on site for at least two 
years after the investigation is discontinued and the US FDA is notified.   
 
Study records will be maintained on site for the entire period of study implementation. No 
study records will be moved to an off-site location or destroyed prior to receiving 
approval from both DAIDS.   
 
11.2 Study Coordination 
 
Dr. Benigno Rodriguez holds the IND for this study. DAIDS will be informed of all 
communications with the FDA. Copies of all correspondence from the FDA, and all 
safety reports will be forwarded to DAIDS, for cross-referencing with other INDs for the 
study products.   
 
Study implementation will follow the most recent DAIDS Medical Officer and FDA 
approved protocol. All amendments will be signed off by the DAIDS Medical Officer and 
FDA prior to implementation, unless the change is required to assure patient safety.  
Study implementation will also be guided by a Manual of Operation Procedures that 
provides further instructions and operational guidance on conducting study visits; data 
and forms processing; specimen collection, processing, and shipping; AE assessment, 
management and reporting; dispensing study products and documenting product 
accountability; and other study operations.  
 
Close coordination among protocol team members is necessary to track study progress, 
respond to queries about proper study implementation, and address other issues in a 
timely manner. Rates of accrual, retention, follow-up, and AE incidence will be monitored 
closely by the team. 
 
 


 
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11.3 Clinical Site Monitoring and Record Availability 
 
Monitoring of the study will be done in compliance with the Requirements for On-Site 
Monitoring of DAIDS Funded and/or Sponsored Clinical Trials, GCP, and FDA 
regulations 
21 
CFR 
Part 
312: 
http://www.niaid.nih.gov/LabsAndResources/resources/DAIDSClinRsrch/Documents/ons
itemonitor_reqs.pdf  
 
Monitoring visits may include any or all of the following activities:   
 
• 
Assess compliance with the study protocol, Good Clinical Practices (GCP) 
guidelines, and applicable regulatory requirements, including US CFR Title 45 Part 
46 and Title 21 Parts 50, 56, and 312 
• 
Review informed consent forms, procedures, and documentation 
• 
Perform source document verification to ensure the accuracy and completeness of 
study data 
• 
Verify proper collection and storage of biological specimens 
• 
Verify proper storage, dispensing, and accountability for investigational study 
products 
• 
Assess implementation and documentation of internal site quality management 
procedures 
• 
Assess site staff training needs 
 
Site investigators will allow study monitors to inspect study facilities and documentation 
(e.g., informed consent forms, clinic and laboratory records, other source documents, 
case report forms), as well as observe the performance of study procedures.  
Investigators also will allow inspection of all study-related documentation by authorized 
representatives of the DAIDS and the US regulatory authorities.  A site visit log will be 
maintained at the study sites to document all visits. The outcomes of the monitoring 
visits and the subsequent reports of resolutions of any identified problems will be 
provided to the Sponsor of the IND application, Dr. Benigno Rodriguez. 
 
The site investigator will make study documents (e.g., consent forms, drug distribution 
forms, CRFs) and pertinent hospital or clinic records readily available for inspection by 
the local IRB, the site monitors, the NIAID, the OHRP, or the FDA or designee for 
confirmation of the study data.  
 
11.4 Adverse Event Reporting 
 
11.4.1 Definitions 
 
11.4.1.1  Adverse event (AE) 
 
An AE is any untoward medical occurrence in a participant who is 
being administered a study agent/intervention, but does not 
necessarily 
have 
a 
causal 
relationship 
with 
the 
study 
agent/intervention. An AE can therefore be any unfavorable and 
unintended sign (including an abnormal laboratory finding), symptom, 


 
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or disease temporally associated with the use of the study 
agent/intervention, 
whether 
or 
not 
related 
to 
the 
study 
agent/intervention.  
 
11.4.1.2 Adverse Reaction 
 
 
An adverse reaction is defined as any adverse event caused by the 
use of a drug. Adverse reactions are a subset of all suspected adverse 
reactions for which there is reason to conclude that the drug caused 
the event.  
 
11.4.1.3 Suspected 
 
A suspected adverse reaction is defined as any adverse event for 
which there is a reasonable possibility that the drug caused the 
adverse event. For the purposes of IND safety reporting, “reasonable 
possibility” indicates that there is evidence to suggest a causal 
relationship between the drug and the adverse event. A suspected 
adverse reaction implies a lesser degree of certainty about causality 
than an adverse reaction.  
 
11.4.1.4 Unexpected 
 
An adverse event or suspected adverse reaction is considered 
unexpected if it is not listed in the package insert, or is not listed with 
the same characteristics or severity observed in the trial, or is not 
consistent with the risk information described elsewhere in the current 
protocol.  
 
Adverse events that would be anticipated to occur as part of the 
disease process are considered unexpected for the purposes of 
reporting because they would not be listed in the investigator brochure. 
For example, a certain number of non-acute deaths in a cancer trial 
would be anticipated as an outcome of the underlying disease, but 
such deaths would generally not be listed as a suspected adverse 
reaction in the investigator brochure.  
 
Some adverse events are listed in the package insert as occurring with 
the same class of drugs, or as anticipated from the pharmacological 
properties of the drug, even though they have not been observed with 
the drug under investigation. Such events would be considered 
unexpected until they have been observed with the drug under 
investigation.  
 
 
 
 
 


 
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11.4.1.5 Serious 
 
An adverse event or suspected adverse reaction is considered serious 
if, in the view of either the investigators or sponsor, it results in any of 
the following outcomes:  
 
• 
Death  
• 
Life-threatening adverse event  
• 
Inpatient hospitalization or prolongation of existing hospitalization  
• 
A persistent or significant incapacity or substantial disruption of 
the ability to conduct normal life function  
• 
Congenital anomaly/birth defect  
 
Important medical events that may not result in death, are not life-
threatening, and do not require hospitalization may be considered 
serious when, based upon appropriate medical judgment, they may 
jeopardize the patient or subject and may require medical or surgical 
intervention to prevent one of the outcomes listed in this definition. 
Examples of such medical events include allergic bronchospasm 
requiring intensive treatment in an emergency room or at home, blood 
dyscrasias or convulsions that do not result in inpatient hospitalization, 
or the development of drug dependency or drug abuse.  
 
11.4.1.6 Life-Threatening 
 
An adverse event or suspected adverse reaction is considered life-
threatening if, in the view of either the investigators or sponsor, its 
occurrence places the patient or subject at immediate risk of death. It 
does not include an adverse event or suspected adverse reaction that, 
had it hypothetically occurred in a more severe form, might have 
caused death. 
 
 
11.4.2 Expedited Adverse Event Reporting to the DAIDS Medical Officer  
 
If a death occurs during the treatment phase of the study or within 30 days after 
the last administration of the study drug(s) and it is determined to be related 
either to the study drug(s) or to a study procedure, the investigators or his/her 
designee must notify the SMC Chair (or qualified alternate) and the DAIDS 
Medical Officer no later than 3 reporting days after the investigators become 
aware of the event. For the purposes of expedited reporting to the SMC and the 
DAIDS Medical Officer, the definition of a “reporting day” in Version 2.0 of the 
DAIDS EAE Manual will be used.  
 
 
11.4.3 Reporting to the University Hospitals of Cleveland Case Medical Center 
(UHCMC) Institutional Review Board (IRB) 
  
In compliance with the UHCMC IRB policy titled “Event Reporting – 
Unanticipated Problems, Adverse Events, and Protocol Deviations”, the Principal 


 
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Investigators will report all non-fatal events meeting the UHCMC IRB definition of 
unanticipated problem involving risk to participants or others within 14 calendar 
days of awareness of the event. All fatal events will be reported to the IRB within 
7 calendar days of awareness of the event. 
 
11.4.4 Expedited Reporting to the Food and Drug Administration and the DAIDS 
Medical Officer  
 
This study is being conducted under an IND held by Dr. Benigno Rodriguez. Dr. 
Rodriguez and Dr. Lederman, study co-chairs, will be responsible for determining 
whether or not the suspected adverse reaction meets the criteria for expedited 
reporting in accordance with Federal Regulations (21CFR 312.32).  
 
The Investigators will report in an IND safety report any suspected adverse 
reaction (see section 11.4.1.3) that is both serious (see section 11.4.1.5) and 
unexpected (see section 11.4.1.4). If the adverse event does not meet all three of 
the definitions, it will not be submitted as an expedited IND safety report.  
 
The timeline for submitting an IND safety report to FDA is no later than 15 
calendar days after the Investigator determines that the suspected adverse 
reaction qualifies for reporting (21 CFR 312.32(c)(1)).  
 
Any unexpected fatal or life-threatening suspected adverse reaction will be 
reported to FDA no later than 7 calendar days after the Investigator’s initial 
receipt of the information (21 CFR 312.32(c)(2)).  
 
Any relevant additional information that pertains to a previously submitted IND 
safety report will be submitted to FDA as a Follow-up IND Safety Report without 
delay, as soon as the information is available (21 CFR 312.32(d)(2)).  
 
11.4.5 Reporting Requirements for this Study 
 
The SAE Reporting Category, as defined in Version 2.0 of the DAIDS EAE 
Manual, will be used for this study. The study agent for which expedited reporting 
is required is tocilizumab (ACTEMRA®)/placebo. In addition to the EAE reporting 
category identified above, other AEs that will be reported in an expedited manner 
are:  
 
• 
All incident cancers 
• 
All opportunistic infections listed in section 8.1 
• 
All recurrent serious infections 
• 
All demyelinating conditions 
• 
All occurrences of an AST or ALT level above 5xULN 
• 
All occurrences of an ANC below 500 cells/mm3 
• 
All occurrences of a platelet count below 50,000/mm3 
• 
All gastrointestinal perforations 
 
 


 
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11.4.6 Grading Severity of Events 
 
The Division of AIDS Table for Grading the Severity of Adult and Pediatric 
Adverse Events, Version 2.0, November 2014, available at http://rsc.tech-
res.com/safetyandpharmacovigilance will be used for grading severity of events 
in this study.  
 
11.4.7 Relationship to Study Agent  
 
The Principal Investigators will determine if there is a reasonable possibility that 
TCZ/placebo caused or contributed to the AE. The relationship assessment, 
based on clinical judgment, will rely on the following:  
 
• 
A temporal relationship between the event and administration of 
TCZ/placebo,  
• 
A plausible biologic mechanism for TCZ/placebo to cause the AE  
• 
Another possible etiology for the AE,  
• 
Previous report of similar AEs associated with TCZ/placebo  
• 
Recurrence of the AE after re-challenge or resolution after de-challenge.  
 
The terms used to assess the relationship of an event to TCZ/placebo are:  
 
• 
Definitely related – The AE is clearly related to TCZ/placebo  
• 
Probably related – The AE is likely related to TCZ/placebo 
• 
Possibly related – The AE may be related to TCZ/placebo 
• 
Probably not related – The AE is not likely related to TCZ/placebo 
• 
Not related – The AE is clearly NOT related to TCZ/placebo 
 
When an AE is assessed as “not related” to TCZ/placebo, an alternative etiology, 
diagnosis or explanation for the SAE will be provided. If new information 
becomes available, the relationship to assessment of any AE will be reviewed 
and updated, as required.  
 
11.4.8 Expedited AE Reporting Period 
 
The protocol-defined EAE Reporting Period for this protocol is the entire study 
duration for an individual subject (from study enrollment until study completion or 
discontinuation of the subject from study participation for any reason). After the 
protocol-defined AE reporting period, unless otherwise noted, only SUSARs as 
defined in Version 2.0 of the EAE Manual will be reported to DAIDS if the study 
staff become aware of the events on a passive basis (from publicly available 
information). 
 
11.4.9 Reporting Procedures 
  
All subjects will be followed for possible adverse events throughout their 
involvement in the study, including issues with study conduct. At each study visit, 
research staff will elicit subject input as to discomforts or adverse experiences. 


 
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All grade ≥2 AEs will be reported to the Principal Investigators on a daily basis. A 
complete blood count, complete metabolic panel as defined in 6.3.5.1, CD4 T cell 
count, and plasma HIV-1 RNA level will be performed on most visits. The 
Principal Investigator will obtain these safety data in “real-time” (i.e., within 1-10 
days of a study visit) when laboratory values become available. The Principal 
Investigators will review these data within that timeframe, assess degree of 
severity, and assess the relationship to study agent/intervention.  
 
The following adverse events will be reported: adverse events graded 3 and 
above, and any possibly, probably, or definitely related, unexpected, and serious 
adverse events. These AEs will be reported to the Safety Monitoring Committee 
(SMC), study sponsor, FDA, and DAIDS Medical Officer. Reporting to the 
UHCMC IRB will follow current UCHCMC IRB policy (see section 11.4.3). 
 
Details of all serious, life-threatening, or fatal adverse events will be sent to the 
SMC and DAIDS Medical Officer no later than 3 reporting days after the 
investigators become aware of the event. For the purposes of expedited 
reporting to the SMC and the DAIDS Medical Officer, the definition of a “reporting 
day” in Version 2.0 of the DAIDS EAE Manual will be used. Reporting to the 
UHCMC IRB will follow current UCHCMC IRB policy (see section 11.4.3). 
Specifically, the following will be reported in writing: (1) all serious adverse 
events associated with the study procedures; and (2) any serious incidents or 
problems involving the conduct of the study or patient participation, including 
problems with the recruitment or consent processes.  
 
12.0 HUMAN SUBJECTS 
 
12.1 IRB Review and Informed Consent 
 
This protocol and the informed consent document and any subsequent modifications will 
be reviewed and approved by the IRB of University Hospitals Case Medical Center. A 
signed consent form will be obtained from the subjects. The consent form will describe 
the purpose of the study, the procedures to be followed, and the risks and benefits of 
participation. A copy of the consent form will be given to the subject, and this fact will be 
documented in the subject’s record. 
 
12.2 Subject Confidentiality 
 
All laboratory specimens, evaluation forms, reports, and other records that leave the site 
will be identified by coded number only to maintain subject confidentiality. All records will 
be kept locked. All computer entry and networking programs will be done with coded 
numbers only. Clinical information will not be released without written permission of the 
subject, except as necessary for monitoring by the IRB, NIAID, OHRP, FDA or designee.  
12.3 Study Discontinuation 
 
The study may be discontinued at any time by the IRB, the NIAID, the OHRP, the FDA, 
or other government agencies as part of their duties to ensure that research subjects are 
protected.  


 
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The SMC will monitor the occurrence of all grade ≥2 signs, symptoms, diagnoses, or 
laboratory abnormalities.  
 
The SMC will review accrual, toxicity summaries, off-treatment and off-study rates, and 
reasons broken down by study arms. Meetings of the SMC are described in section 9.4. 
The SMC will be asked to consider the following regarding safety events: the grade of 
the event, the time to resolution (if any), and the site clinician’s judgment of the 
relationship to treatment. The first interim safety review by the SMC is planned 3 months 
after the first subject enrolls and approximately every 3 months thereafter, but expedited 
reviews will occur whenever the threshold for temporary enrollment discontinuation is 
reached. Criteria for temporary enrollment discontinuation and expedited SMC review 
are:  
 
• 
Three or more participants have experienced a grade 3 AE that is deemed 
possibly, probably, or definitely related to study treatment 
• 
Two or more participants have experienced a grade 4 AE that is deemed 
possibly, probably, or definitely related to study treatment 
• 
Any death occurs on study that is deemed possibly, probably, or definitely related 
to study treatment 
 
The SMC will review the events whenever any of the criteria above is met, and 
recommend, based on the results of the review, whether the study can proceed as 
planned, proceed with modifications, or be discontinued.   
 
12.4 Human Subjects Involvement, Characteristics, and Design 
 
Up to 36 participants will be enrolled in the clinical trial. Potential participants will be 
recruited primarily from the Special Immunology Unit, the HIV clinic of University 
Hospitals Case Medical Center, although recruitment from other area hospitals through 
direct outreach and targeted advertisement is also possible. Characteristics of the study 
population, inclusion/exclusion criteria, and planned study procedures are described in 
the clinical protocol. No vulnerable populations will be included in these studies.  
 
12.5. Sources of Materials   
 
Laboratory and clinical staff have received Good Clinical Practices (GCP) and Good 
Clinical Laboratory Practices (GCLP) training per their role in the study. Clinical 
monitoring and screening laboratories will be run in CLIA certified labs at University 
Hospitals Case Medical Center. All specimens will be stored with coded identifiers only 
in restricted-access laboratories. The CWRU/UHC CFAR Patient Care and Research 
Database personnel and the study data manager will store, manage and retrieve all 
study-related data, which will be stored on firewalled servers at UHCMC, in full 
compliance with relevant HIPPAA requirements. All study records will be stored and 
accessed using only a participant identifier (PID), and locator data linking identifiable 
information to the PID will be kept in a separate database in a different location to 
ensure the confidentiality of these data. Clinical information will not be released without 
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FDA, the NIAID, the OHRP or the subject’s designees. Information about the subject’s 
participation will not be shared with persons who are not directly involved with the 
research subjects or as identified in the HIPAA consent. 
 
12.6 Potential Risks and Risk Mitigation Strategies 
 
12.6.1  Risks of Tocilizumab  
 
 
12.6.1.1 Risk Mitigation Strategy for Serious Infections 
 
To mitigate the risk of serious infections, individuals with any of the 
following conditions will be excluded from enrolling in this study: 
 
• 
A screening CD4 T-cell count <350 cells/mm3 
• 
A history of AIDS-defining opportunistic infections, as listed in 
section 4.2.16 
• 
An absolute neutrophil count <2000 cells/mm3 
• 
A history of TB, latent TB, or a positive screening test for TB 
• 
An active local or systemic infection 
• 
Use of immunosuppressive or immune modulating therapy 
• 
Use of any investigational agent 
• 
Co-infected with HBV or HCV  
• 
History of having received a live attenuated vaccine within 30 days 
of study entry or an indication for a live attenuated vaccine  
 
In addition to the exclusion criteria above, exposure to TCZ will be 
minimized by administering only three doses, the first of which will be 
at the lower 4 mg/Kg level, and the last of which will be given at day 
56. In previous studies of TCZ for treatment of RA, the earliest 
opportunistic infection occurred at day 115 after initiation of treatment 
with TCZ. In the 6-month safety database, most serious non-
opportunistic infections occurred after the fifth dose of TCZ. 
Therefore, by reducing the duration of exposure, it is expected that 
the overall risk of serious infections will be reduced as well.  
 
If a serious infection develops, study drug will be held until the 
infection is adequately controlled. Study drug administration will be 
interrupted if the ANC is <1,000 cells/mm3. Screening for tuberculosis 
will be done at screening and at week 10, and a negative result will be 
required before the first dose of study agent in each of the two periods 
of the trial (week 0 and week 20 visits). 
 
 
 
12.6.1.2 Risk Mitigation Strategy for Hypersensitivity Reactions 
 
 
To mitigate the risk of hypersensitivity reactions including anaphylaxis: 
 
• 
Patients with a known allergy/sensitivity or any hypersensitivity to 


 
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components of the study drug or its formulation will be excluded. 
• 
All doses of study agent will be administered on an inpatient basis 
in the Dahms Clinical Research Unit, where subjects will be 
monitored for a minimum of 30 minutes following the dose of study 
drug by personnel with life support training and access to 
adequate life support equipment and resuscitation medication. 
• 
A severe allergic reaction related to study treatment will be 
grounds for study treatment discontinuation. 
 
 
12.6.1.3  Risk Mitigation Strategy for Gastrointestinal Perforations 
 
To mitigate the risk of gastrointestinal perforations, subjects at 
increased risk for gastrointestinal perforation, such as those with a 
history 
of 
diverticulitis, 
intestinal 
perforation, 
distal 
intestinal 
obstruction, or lower gastrointestinal bleeding, will be excluded. In the 
integrated safety review from clinical trials (67), the average age of 
patients who developed gastrointestinal perforations was 58.5 years. 
Therefore, subjects over 60 years of age will be excluded from this 
study. In addition, use of other immune suppressive agents will be 
prohibited. All subjects will be monitored for signs or symptoms of 
gastrointestinal perforation at each visit. Subjects who present with 
new onset of abdominal symptoms will be immediately referred for 
evaluation by a qualified healthcare professional to rule out 
gastrointestinal perforation. Subjects who develop a gastrointestinal 
perforation during study will be required to discontinue study 
treatment permanently. 
 
 
12.6.1.4 Risk Mitigation Strategy for Infusion Reactions 
 
To reduce the risk of severe infusion reactions, subjects will be closely 
monitored during and after infusion as inpatients with frequent vital 
sign monitoring, and immediate availability of qualified medical 
treatment and resuscitation medications and equipment. A qualified 
healthcare professional will be present in the room for each infusion. 
 
 
12.6.1.5 Risk Mitigation Strategy for Laboratory Abnormalities 
 
12.6.1.5.1 Neutropenia 
 
The risk mitigation plan for neutropenia is consistent with 
the USPI and includes:  
 
• 
Patients with an ANC <2000 cells/mm3 will not be 
permitted to enroll in the study; 
• 
ANC will be measured at each visit 
• 
Should the ANC decrease to ≥500 but ≤1,000 
cells/mm3, the TCZ dose will be interrupted until the 
ANC is >1,000 cells/mm3 and then TCZ will be 


 
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restarted at 4 mg/kg. If the ANC remains above 1,000 
cells/mm3, the dose will be increased again to 8 mg/Kg 
with close clinical and laboratory monitoring.  
• 
Should the ANC decrease to <500 cells/mm3,TCZ will 
be discontinued. 
 
12.6.1.5.2 Thrombocytopenia 
 
The risk mitigation plan for thrombocytopenia is consistent 
with the USPI and includes:  
 
• 
Patients with a platelet count <100,000/mm3 will not be 
enrolled in the study; 
• 
Platelet counts will be measured at each visit; 
• 
Should the platelet count decrease to ≥50,0000 but 
≤100,000/mm3 the TCZ dose will be interrupted until 
the platelet count is >100,000/mm3 and then TCZ will 
be restarted at 4 mg/kg. If the platelet count remains 
above 100,000 /mm3, the dose will be increased again 
to 8 mg/Kg with close clinical and laboratory 
monitoring. 
• 
Should the platelet count decrease to <50,000/mm3 
TCZ will be discontinued. 
 
12.6.1.5.3 AST and ALT Abnormalities 
 
The risk mitigation plan for AST or ALT abnormalities is + 
consistent with the USPI and includes: 
 
• 
Patients with an AST or ALT > 1.5x ULN will be 
excluded from the study. 
• 
Patients with cirrhosis, sever liver disease or active 
hepatitis B or C infection will be excluded from the 
study. 
• 
AST and ALT will be evaluated at each study visit. 
• 
For AST or ALT values persistently > 1.4x to <3x ULN, 
the TCZ dose will be reduced to 4 mg/kg or TCZ will be 
interrupted until the AST and ALT have normalized. 
• 
For AST or ALT values confirmed 3x to 5x ULN, the 
TCZ dose will be interrupted until the values are 1x to 
<3x ULN and the above guidelines will be used. 
• 
For AST or ALT values > 5x ULN TCZ dosing will be 
permanently discontinued.  
 
 
 
12.6.1.5.4 Lipid abnormalities 
 
Total and LDL cholesterol and serum triglycerides will be 
monitored in real time at each study visit beginning with 


 
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study entry, as well as at screening, as part of the Chem23 
panel. Subjects who experience incident lipid abnormalities 
will be referred for adequate medical treatment by a 
qualified healthcare professional, but in light of the short 
duration of the study, isolated lipid abnormalities will not 
require study treatment modification or discontinuation. In 
general, treatment for dyslipidemias by providers in the 
John T. Carey Special Immunology Unit of UHCMC follows 
the ATP III guidelines. Consultation with experts in 
cardiovascular risk is available on-site in the Special 
Immunology Unit by co-investigator Dr. Chris Longenecker. 
 
 
12.6.1.6 Risk Mitigation Strategy for Malignancies 
 
To minimize the risk or emergent or recurrent malignancies, subjects 
with a history of or active cancer will be excluded, and a review of 
interval diagnoses or medical events and a full or targeted physical 
exam will be performed at each visit. Additionally, concomitant 
immunosuppressive medications will be prohibited during the study.  
 
 
12.6.1.7 Risk Mitigation Strategy for Viral Reactivation 
 
Consistent with the USPI, a history of or a positive antibody titer to 
herpes zoster will not be exclusionary for this study. Nonetheless, the 
prohibition of corticosteroid or immune suppressants in this study, and 
the short course of TCZ dosing, 8 weeks, may to some degree mitigate 
the risk of herpes zoster exacerbation in this study.  
 
To reduce the risk of hepatitis B or hepatitis C reactivation, subjects 
with evidence of active hepatitis B (HbsAg, HbeAg, or HBV DNA 
positivity) or C (HCV antibody and HCV RNA positivity) will be 
excluded, and those who are HbcAb-positive at screening will be 
required to receive an antiretroviral regimen including at least one 
agent with HBV activity and will have HBV DNA monitoring throughout 
the study. Subjects who develop a detectable HBV DNA while on study 
will require permanent study discontinuation. Liver enzymes will be 
monitored throughout the study on all subjects, regardless of 
serological status.    
 
 
 
 
12.6.1.8 Risk Mitigation Strategy for Cytochrome P450 Inhibition and 
Decreased Plasma Levels of Antiretrovirals 
 
To minimize the risk of reaching levels of antiretrovirals that might 
compromise antiviral activity, subjects receiving non-boosted protease 
inhibitors will be excluded from the study, as will subjects whose trough 
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inhibitors and non-nucleoside reverse transcriptase inhibitors will be 
measured at each study agent administration visit, as well as at weeks 
10 and 30, two weeks after the last dose of study agent in each of the 
periods of the trial using validated LC/MS/MS methods. If there is 
evidence of incomplete virologic suppression in a subject whose trough 
levels of antiretroviral are low or low antiretroviral levels are 
documented in two consecutive visits, study treatment will be 
permanently discontinued.  
 
 
12.6.1.9 Risk Mitigation Strategy for Demyelinating Disorders 
 
To minimize the risk of emerging demyelinating disorders, subjects with 
a history of these conditions will be excluded from the study. At each 
visit, a complete review of symptoms and new diagnoses will be 
conducted, and subjects who describe any neurologic symptoms 
suggestive of a demyelinating disorder will be immediately referred for 
evaluation by a qualified specialist. Subjects who develop a 
demyelinating disorder, or a neurologic condition that is deemed to be 
consistent with a demyelinating disorder, will be required to discontinue 
study treatment permanently.  
 
 
12.6.1.10Risk Mitigation Strategy for Women of Reproductive Potential 
 
The following measures will be taken to minimize the risks of fetal TCZ 
exposure in women of childbearing potential:  
 
• 
A negative pregnancy test will be required at enrollment and at each 
study visit where drug is administered, prior to administration of 
study drug. 
• 
Women must agree to not to participate in a conception event 
• 
Two forms of birth control are required - oral hormonal contraception 
will not be considered adequate because of potential drug-drug 
interactions. 
• 
Use of contraception will be verified at each visit before 
administration of study drug. 
• 
A sexually active woman who does not report using two protocol 
defined acceptable methods of contraception will not receive study 
medication at that visit. 
• 
Should a woman become pregnant while participating in the study, 
study drug will be discontinued; the woman will be enrolled in the 
ACTIMERA (TCZ) Pregnancy Registry and followed for the outcome 
of the pregnancy. 
 
In addition, the investigators will follow FDA updates to the USPI and 
the literature for reports from the TCZ pregnancy registry, and reassess 
the inclusion of women of child bearing potential if appropriate.  
 
 


 
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12.6.2 Enemas (for the subset of participants agreeing to rectal biopsies) 
 
The main risk from having an enema is temporary discomfort. To receive an 
enema, a hollow soft plastic tube about the thickness of a pencil is used to put 
approximately 120 mL of enema fluid into the rectum to stimulate a bowel 
movement with stool evacuation and flush it out.  This may cause a “bloated” or 
“cramping” feeling. Some air may be pumped into the rectum as well, causing 
flatulence.  The tube is small, but it might cause some anal or rectal discomfort if 
the subject has any hemorrhoids or other painful conditions. To minimize the risk 
of symptoms derived from enema administration, all subjects will receive 
guidance on safe administration techniques, and will be instructed to follow the 
package directions closely.    
 
12.6.3 Flexible Sigmoidoscopy and Biopsies 
 
Risks associated with lower gastrointestinal endoscopy include colitis from 
chemicals for endoscope sterilization, bowel perforation, bleeding, diverticulitis, 
and infection. Rectosigmoid biopsies in this study will be obtained through 
flexible sigmoidoscopy rather than full colonoscopy, as colonoscopy has been 
shown to be associated with a still low, but significantly greater risk of 
complications than rectosigmoidoscopy (85). To minimize these risks, subjects 
with a history of a bleeding disorder, recent major anorectal surgical procedures, 
or significant anatomic lesions or active conditions involving the distal large 
bowel will be excluded. Additionally, agents containing aspirin and other 
antiplatelet agents will be prohibited within 7 days of the flexible sigmoidoscopy 
procedure, and subjects who require anticoagulant agents whose pharmacologic 
action cannot be interrupted rapidly will be excluded. Further, all procedures will 
be performed by trained, experienced endoscopists using state-of-the-art 
equipment, and a safety follow-up contact will be included to help detect potential 
complications.  
 
12.6.4 Intravenous Infusion 
 
Intravenous infusion can be associated with infection, superficial or deep 
thrombophlebitis, hematomas, air embolism, and tissue damage. The study 
agent will be administered through a peripheral IV line, so the risk of serious 
complications is exceedingly small. Sterile supplies and technique will be used 
throughout the study, and all personnel administering the study drug have 
extensive experience with infusion of biological products and intravenous 
medications. If peripheral vascular access cannot be secured for a given 
participant, no attempt will be made to obtain central access in order to avoid the 
additional risk that this entails, and the participant will be removed from the study.   
 
12.6.5 Blood Sample Collection 
 
The most common risks of blood sample collection are pain at the puncture site, 
bruising, and a feeling of lightheadedness. To minimize these risks, blood draws 
will be performed by trained personnel, and will be performed in a secure 


 
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environment with access to first aid equipment, bandages, and trained healthcare 
professionals.  
 
12.7 Adequacy of Protection against Risks 
 
  
12.7.1 Recruitment and Informed Consent 
 
Before the initiation of any study procedures, subjects will be informed about the 
study and asked to sign an IRB approved informed consent/HIPAA document. 
Subjects will be consented in a private exam room.  Subjects will be given time to 
read the consent, ask questions and consider the risks and/or benefits to 
participation in this research study prior to obtaining their signature. All subjects 
enrolled in the study will be given a copy of their signed and dated informed 
consent document. This consenting process will be done by trained research 
staff at the Case Clinical Trials Unit or at the DCRU.  
 
12.7.2 
Protections against Specific Study-related Risks 
 
An extensive risk mitigation strategy has been implemented to address risks 
derived specifically from the study treatments and procedures. Details of the risk 
minimization strategy for each risk category are provided above in section 12. 6. 
All study-related activities will be conducted in private areas to protect patient 
confidentiality.  
 
12.8 Potential Benefits of the Proposed Research to Human Subjects and Others   
 
Participants in this trial are not expected to derive a direct benefit from their participation. 
If this trial provides proof of concept for the notion that IL-6 may play a central role in the 
development of inflammation-related complications in treated HIV infection, the results 
could offer the starting point for the implementation of a therapeutic strategy to halt this 
inflammatory process and that could result in a tangible clinical benefit to persons living 
with HIV/AIDS, including those directly involved in the study.   
 
12.9 Importance of the Knowledge to Be Gained  
 
Immune activation and inflammation are critical pathogenesis determinants in HIV 
infection in the era of effective antiretroviral therapy. Identifying the critical pathways that 
perpetuate this process and that lead to end-organ complications is a central goal of 
current HIV research. A large body of data now exists indicating that uncontrolled 
inflammation is one of the most significant contributors to the excess mortality observed 
even among HIV-infected persons with controlled plasma HIV RNA. Therefore, if a 
pivotal mediator can be found that is shown to play a meaningful causal role in this 
process, as we propose IL-6 does, therapeutic manipulation of that mediator might yield 
reductions in disease burden and even survival benefits in HIV infection. Therefore, the 
potential general benefit of the proposed studies is considerable.   
 
 
 


 
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12.10 Data and Safety Monitoring Plan 
 
The two PIs, Drs. Rodriguez and Lederman, both experienced HIV clinical trialists, will 
review all adverse events, determine their relationship to study procedures, and 
generate reports to the IRB and FDA as needed. The data manager will prepare 
quarterly blinded data reports, and inconsistencies in data elements will be resolved by 
review of primary sources, interview with research personnel, and general consensus 
among study team members. The protocol statistician will be responsible for preparing 
the overall data reports, and for alerting the team to trends in adverse event frequency or 
data discrepancies. External data monitoring will be conducted by the DAIDS contractor 
PPD, which monitors most other network studies carried out in the Case/UHCMC 
Clinical Trials Unit. Trial safety will be monitored by an SMC (see section 9.4). 
 
12.11 ClinicalTrials.gov Requirements 
 
 
When regulatory approval is secured, this study will be registered with ClinicalTrials.gov. 
Results information (including adverse events) will be reported no later than 1 year after 
the primary completion date per Food and Drug Administration Amendments Act 
(FDAAA) requirements (http://grants.nih.gov/ClinicalTrials_fdaaa/steps.htm). 
 
12.12 Inclusion of Women and Minorities 
 
Both men and women will be included in the trial. Minorities, including Spanish-speaking 
persons, will be eligible to enroll in the trial, and a Spanish language consent will be 
available for them.  
 
12.13 Inclusion of Children 
 
Children ages 18 to 21 will be included in this study.  
 
13.0 PUBLICATION OF RESEARCH FINDINGS 
 
Publication of the results of this trial will be decided by consensus of the study team.  
 
14.0 BIOHAZARD CONTAINMENT 
 
As the transmission of HIV and other blood-borne pathogens can occur through contact 
with contaminated needles, blood, and blood products, appropriate blood and secretion 
precautions will be employed by all personnel in the drawing of blood and shipping and 
handling of all specimens for this study, as currently recommended by the Centers for 
Disease Control and Prevention and the National Institutes of Health. 
 
All dangerous goods materials, including diagnostic specimens and infectious 
substances, will be transported using packaging mandated by CFR 42 Part 72, as per 
the International Air Transport Association (IATA) Dangerous Goods Regulations.  


 
 
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