Conditions: HIV Infections
Keywords: HIV latency Disulfiram Vorinostat Latency Reversing Agents Histone Deacetylase Inhibitors (HDACi)
Allocation: NA | Intervention model: SINGLE_GROUP
Enrollment: 5
Healthy volunteers: no

Brief summary:
Antiretroviral therapy (ART) dramatically reduces Human Immunodeficiency Virus (HIV) replication leading to restoration of immune function and a near normal life expectancy, but treatment is lifelong and there is no cure. The major barrier to a cure is the persistence of long lived cluster of differentiation 4 (CD4+) T-cells that contain a "silenced" form of HIV, called HIV latency.

The purpose of this research is to investigate whether it may be possible to reduce the amount of dormant HIV infection in immune cells, by "turning on" or activating the virus and hence force it out of the latently infected memory T cells. This leads to production of HIV by the cell, which will either die or will be recognized and eliminated by the immune system. As very few T cells are latently infected with HIV, the death of these cells is not expected to affect the function of the immune system and further infection of new cells is expected to be prevented by ART.

Detailed description:
One strategy aimed at reducing the frequency of latently infected cells in HIV-infected individuals on antiretroviral therapy (ART) is the use of pharmacological agents to reverse HIV latency, thereby initiating virus-mediated cell lysis or immune-mediated killing. Recent clinical trials of latency reversing agents (LRAs) in HIV infected subjects on ART, including histone deacetylase inhibitors (HDACi) and the anti-alcoholism drug disulfiram, have shown that inducing an increase in Cell Associated Unspliced (CA-US) HIV RNA or plasma HIV RNA is possible. Yet, these interventions did not have a demonstrable effect on the frequency of latently infected cells or time to viral rebound after cessation of ART, potentially because latency reversal alone didn't trigger an adequate immune response or cell death or that the potency of latency reversal with a single-agent intervention over a very short period of time, lacked sufficient potency, as suggested by recent in vitro studies. It is highly likely that long-term remission off ART will require interventions that lead to both a reduction in latently infected cells and an increase in HIV-specific immunity, therefore identifying a strategy to increase viral antigens on the surface of latently infected cells will be a key component of this strategy.

Arms:
arm 1: Participants current ART regimen:

2 grams disulfiram by mouth per day for a total of 28 days

400mg vorinostat by mouth per day on days 8, 9,10 and days 22, 23, 24

Interventions: intervention 1: Disulfiram, (National Drug Code) NDC 0378-4141-01 intervention 2: Vorinostat, NDC 00006-0568-40
Intervention descriptions: intervention 1: This study will provide open label disulfiram. Participants will take 2 grams (4x500mg tablets) of disulfiram per day for a total of 28 days intervention 2: This study will provide open label vorinostat. Participants will take 400mg (4x100mg capsules) of vorinostat per day on days 8, 9, 10 and days 22, 23, 24.

Protocol document:
Prot_SAP_000.pdf: 
 
Study Title: Combination Latency Reversal with High Dose 
Disulfiram plus Vorinostat in HIV-infected individuals on ART 
(DIVA): A Single Arm Clinical Trial 
 
Protocol ID: MSD IIS-55750 
 
Version: 4.0 
 
Date: 17 June 2019 
 
NCT number: NCT03198559 
 
 
Certain information within this clinical study report has been redacted (ie, specific 
content is masked irreversibly from view with a black bar) to protect either personally 
identifiable information or company confidential information. 
This may include, but is not limited to, redaction of the following: 
• Named persons or organizations associated with the study; 
• Proprietary information, which is considered confidential information; 
• Other information as needed to protect confidentiality of Merck, personal 
information, or to otherwise protect the integrity of the clinical study. 
 
 


 
Study Name: Combination Latency Reversing Therapy with Disulfiram plus Vorinostat in HIV Infected Individuals on antiretroviral 
therapy (ART): A Single Arm, Clinical Trial 
Protocol ID: MDS-IIS-55750 
Version & date: 4.0, Dated 17 June 2019 
Page 1 of 46 
 
PROTOCOL  
Combination Latency Reversal with High 
Dose Disulfiram plus Vorinostat in HIV-
infected individuals on ART (DIVA): A Single 
Arm Clinical Trial 
 
Protocol ID: MSD IIS-55750 
Version: #4.0 
Date: 17 June 2019 
 
Author/s: 
Prof Sharon Lewin, Dr James McMahon and Dr Thomas Rasmussen 
 
Sponsor/s: 
The Peter Doherty Institute for infection and Immunity, The University of Melbourne 
 
 
CONFIDENTIAL 
 
This document is confidential and the property of The Peter Doherty Institute for Infection and 
Immunity, The University of Melbourne.  No part of it may be transmitted, reproduced, published, 
or used without prior written authorization from the institution. 
 
Statement of Compliance 
 
This study will be conducted in compliance with all stipulation of this protocol, the conditions of 
the ethics committee approval, the NHMRC National Statement on ethical Conduct in Human 
Research (2007) and the Note for Guidance on Good Clinical Practice (CPMP/ICH-135/95). 
 
Approval: 
 
 
17 June 2019 
Sponsor Signature: Professor Sharon Lewin 
 
Date 
 


Study Name: Combination Latency Reversing Therapy with Disulfiram plus Vorinostat in HIV Infected Individuals on antiretroviral 
therapy (ART): A Single Arm, Clinical Trial 
Protocol ID: MDS-IIS-55750 
Version & date: 4.0, Dated 17 June 2019 
Page 2 of 46 
PROTOCOL AGREEMENT 
I have read the protocol specified below.  In my formal capacity as Investigator, my duties 
include ensuring the safety of the study participants enrolled under my supervision and 
providing the Doherty Institute with complete and timely information, as outlined in the 
protocol.  It is understood that all information pertaining to the study will be held strictly 
confidential and that this confidentiality requirement applies to all study staff at this site.  
Furthermore, on behalf of the study staff and myself, I agree to maintain the procedures 
required to carry out the study in accordance with accepted GCP principles and to abide by 
the terms of this protocol. 
Protocol Number: 
MSD-II-55750 
Protocol Title: 
Combination Latency Reversing Therapy with Disulfiram plus Vorinostat 
in HIV Infected Individuals on Antiretroviral Therapy (ART): A Single 
Arm Clinical Trial  
Protocol Date:  
17 June 2019 
 
 
 
 
Investigator Signature  
 
Date 
 
Print Name and Title 
Site Name 
 
Address 
 
 
 
 
 
 
 
Phone Number 
 
  
 


Study Name: Combination Latency Reversing Therapy with Disulfiram plus Vorinostat in HIV Infected Individuals on antiretroviral 
therapy (ART): A Single Arm, Clinical Trial 
Protocol ID: MDS-IIS-55750 
Version & date: 4.0, Dated 17 June 2019 
Page 3 of 46 
TABLE OF CONTENTS 
 
PROTOCOL AGREEMENT .................................................................................................... 2 
Table of Contents .................................................................................................................. 3 
1. 
Glossary of Abbreviations & Terms ......................................................................... 9 
2. 
Researchers .............................................................................................................. 10 
2.1 
Coordinating Principal Investigator ..................................................................... 10 
2.2 
Associate Investigators ....................................................................................... 10 
2.3 
Collaborator ........................................................................................................ 11 
2.4 
Contact ................................................................................................................ 11 
3. 
Introduction/Background Information.................................................................... 11 
3.1 
Lay Summary ...................................................................................................... 11 
3.2 
Introduction ......................................................................................................... 12 
3.3 
Background information ...................................................................................... 13 
4. 
Study Objectives ...................................................................................................... 14 
4.1 
Hypotheses ......................................................................................................... 14 
4.2 
Objectives ........................................................................................................... 15 
4.3 
Outcome Measures ............................................................................................. 15 
5. 
Study Design ................................................................................................................ 15 
5.1 
Study Sites .......................................................................................................... 15 
5.2 
Study Design ....................................................................................................... 16 
5.3 
Approximate duration of study participation ........................................................ 16 
5.4 
Approximate duration of the study ...................................................................... 16 
5.5 
Source data ......................................................................................................... 16 
6. 
Study Population ...................................................................................................... 17 
6.1 
Recruitment Procedure ....................................................................................... 17 
6.2 
Inclusion Criteria ................................................................................................. 18 
6.3 
Exclusion Criteria ................................................................................................ 18 
6.4 
Withdrawal from the study .................................................................................. 20 
6.5 
Withdrawal from the Investigational drug(s) ........................................................ 20 
6.6 
Replacements ..................................................................................................... 21 
7. 
Study Treatment .......................................................................................................... 21 
7.1 
Investigational Drugs .......................................................................................... 21 
7.2 
Study Dose and Duration of Study Therapy ....................................................... 22 
7.3 
Drug Supplies and Administration ....................................................................... 22 
7.4 
Drug Storage and Drug Accountability ................................................................ 23 
7.5 
Compliance ......................................................................................................... 23 
7.6 
Concomitant medication(s) ................................................................................. 23 
7.7 
Concomitant Therapy Allowed During the Study ................................................ 23 
7.8 
Concomitant Therapy prohibited during the study .............................................. 23 
8. 
Study Procedures ........................................................................................................ 24 
8.1 
Schedule of Activities .......................................................................................... 24 
8.2 
Visit 1 – Screening .............................................................................................. 25 
8.3 
Visit 2 - Baseline ................................................................................................. 26 
8.4 
Visit 3 – Day 8 ..................................................................................................... 27 
8.5 
Visit 4 – Day 11 ................................................................................................... 27 
8.6 
Visit 5 – Day 22 ................................................................................................... 27 
8.7 
Visit 6 – Day 25 ................................................................................................... 28 


Study Name: Combination Latency Reversing Therapy with Disulfiram plus Vorinostat in HIV Infected Individuals on antiretroviral 
therapy (ART): A Single Arm, Clinical Trial 
Protocol ID: MDS-IIS-55750 
Version & date: 4.0, Dated 17 June 2019 
Page 4 of 46 
8.8 
Visit 7 – End of Treatment .................................................................................. 28 
8.9 
Visit 8 – Safety Visit ............................................................................................ 29 
8.10 
Visit 9 – End of Study .......................................................................................... 29 
9. 
Effect Assessments ..................................................................................................... 30 
9.1 
Plasma HIV RNA ................................................................................................ 30 
9.2 
Tolerability ........................................................................................................... 30 
9.3 
Cell-associated unspliced HIV RNA .................................................................... 30 
9.4 
p24 Expression ................................................................................................... 30 
9.5 
Cell-associated total and integrated HIV DNA .................................................... 30 
9.6 
The Frequency of inducible virus in CD4+ T cells ............................................... 30 
9.7 
Plasma levels of Vorinostat and Disulfiram ......................................................... 31 
9.8 
NEXT-GENERATION RNA SEQUENCING ................................................................. 31 
9.9 
QUNATIFICATION 
OF 
PLASMA 
BIOMARKERS 
OF 
NEUROINFLAMMATION 
AND 
DEGRADATION ................................................................................................................. 31 
9.10 
PLASMA CYTOKINES, CHEMOKINES AND GENE PRODUCTS ..................................... 31 
9.11 
HISTONE ACETYLATION AND PTEFB AND NFKB ACTIVATION .................................. 31 
9.12 
EFFECTS OF VORINOSTAT AND DISULFIRAM ON ASTROCYTES ................................ 31 
10. 
Participant Safety and Withdrawal ......................................................................... 32 
10.1 
Definitions ........................................................................................................... 32 
10.2 
Recording of Adverse Events ............................................................................. 33 
10.3 
Reporting of Serious Adverse Events ................................................................. 34 
10.4 
Suspected Unexpected Serious Adverse Reactions (SUSARS) ........................ 34 
10.5 
Reporting of SUSARs to local health authority ................................................... 34 
11. 
Statistical Methods .................................................................................................. 35 
11.1 
Sample Size Estimation & Justification ............................................................... 35 
11.2 
Analyses of primary and secondary endpoints ................................................... 35 
11.3 
Gene Expression Data and Additional Analyses to Investigate Neurotoxicity 
(sections 9.8 – 9.12) ...................................................................................................... 35 
12. 
Storage of Blood Samples ...................................................................................... 36 
13. 
Ethical Considerations ............................................................................................ 36 
13.1 
Study Approval .................................................................................................... 36 
13.2 
Ethical conduct of the Study ............................................................................... 36 
13.3 
HREC review and Informed Consent .................................................................. 36 
13.4 
Harms, Risks and Inconveniences ...................................................................... 36 
13.5 
Risk/benefit Analysis ........................................................................................... 39 
14. 
Study Monitoring and Quality Assurance .............................................................. 39 
14.1 
The responsibilities of sponsor and principal investigator ................................... 39 
14.2 
Study Monitoring/Audit ........................................................................................ 40 
15. 
Data Handling & Record Keeping ........................................................................... 40 
15.1 
Handling of personal information ........................................................................ 40 
15.2 
Data Management .............................................................................................. 40 
16. 
Finances .................................................................................................................... 41 
17. 
Publication of the Study .......................................................................................... 41 
17.1 
Public registration of study .................................................................................. 41 
17.2 
Publication of the Study ...................................................................................... 41 
18. 
References ................................................................................................................ 42 
Appendix 1 – AUDIT Questionnaire .................................................................................. 44 
 
 


Study Name: Combination Latency Reversing Therapy with Disulfiram plus Vorinostat in HIV Infected Individuals on antiretroviral 
therapy (ART): A Single Arm, Clinical Trial 
Protocol ID: MDS-IIS-55750 
Version & date: 4.0, Dated 17 June 2019 
Page 5 of 46 
STUDY SYNOPSIS  
 
 
Title: 
Combination latency reversing therapy with high dose disulfiram plus 
vorinostat in HIV-infected individuals on antiretroviral therapy (ART): a 
single arm clinical trial 
Short Title: 
Combination HIV latency reversal with disulfiram and vorinostat 
Design: 
Single arm clinical trial 
Sponsor 
The Peter Doherty Institute for Infection and Immunity 
Study Centre: 
Alfred Hospital 
Study Question: 
To assess the feasibility, toxicity and effects of high dose disulfiram and 
vorinostat in HIV individuals on suppressive ART 
Primary Objectives 
Primary efficacy objective:  
To determine the effect of 28 days of high dose disulfiram with 
intermittent administration of 3 days of vorinostat on plasma HIV RNA in 
HIV infected individuals on suppressive ART  
Primary tolerability objective:  
To determine the tolerability of 28 days of high dose disulfiram with 
intermittent administration of 3 days of vorinostat in HIV infected 
individuals on suppressive ART  
Secondary Objective 
To determine the effect of 28 days of high dose disulfiram with 
intermittent administration of 3 days of vorinostat on the frequency of 
latently infected CD4+ T cells in HIV infected individuals on suppressive 
ART 
Inclusion Criteria: 
– 
Age 18-65 years with documented HIV-1 infection  
– 
Receiving combination ART with plasma HIV RNA <50 copies/mL 
for >3 years  
– 
CD4+ T cell count >350/µL at screening  
– 
Able to provide informed consent  
– 
WOCBP with a negative pregnancy test at screening (visit #1) 1 
AND agrees to use one of the following methods of contraception to 
avoid pregnancy 
o 
Complete abstinence from penile-vaginal intercourse from 2 
weeks prior to administration of high dose disulfiram, 
throughout the study, and for at least 2 weeks after 
discontinuation of all study medications  
o 
Double barrier method (male condom/spermicide, male 
condom/diaphragm, diaphragm/spermicide)  
o 
Any intrauterine device (IUD) with published data showing that 
the expected failure rate is <1% per year  
o 
Male partner sterilization confirmed prior to the female 
subject’s entry into the study, and this male is the sole 
partner for that subject  
o 
Approved hormonal contraception (Where other medications to 
be used in the study (e.g., efavirenz and darunavir) are known, 


Study Name: Combination Latency Reversing Therapy with Disulfiram plus Vorinostat in HIV Infected Individuals on antiretroviral 
therapy (ART): A Single Arm, Clinical Trial 
Protocol ID: MDS-IIS-55750 
Version & date: 4.0, Dated 17 June 2019 
Page 6 of 46 
or are likely, to significantly interact with systemic 
contraceptives, resulting in decreased efficacy of the 
contraceptive, then alternative methods of non-hormonal 
contraception are recommended) 
o 
Any other method with published data showing that the 
expected failure rate is < 1% per year. 
– 
Women of non-child-bearing potential defined as: 
o 
> 12 months of spontaneous amenorrhea and ≥ 45 years of 
age, or 
o 
Documented medical history of one of the following: 
hysterectomy, bilateral oophorectomy or tubal ligation. 
– 
Willing to abstain from alcohol consumption from one day before to 
14 days after completing study therapy  
Exclusion Criteria:  
– 
Current alcohol use disorder or hazardous alcohol use (>7 drinks 
per week for women or > 14 drinks per week for men) as 
determined by clinical evaluation  
– 
Current use of metronidazole or any drug formulation that contains 
alcohol or that might contain alcohol, including the gelatin capsule 
and liquid formulations of ritonavir, ritonavir/lopinavir, amprenavir 
and fosamprenavir, and alcohol-containing preparations such as 
cough syrups, or tonics 
– 
Current use of tipranavir or Maraviroc  
– 
Current use of zidovudine, stavudine or didanosine (as disulfiram 
potentially has potent irreversible inhibitory effects on mitochondrial 
metabolism and hence could exacerbate the toxicity of these drugs)  
– 
Concurrent use of rivaroxaban (a CYP3A metabolized medication) 
as the cytochrome P450 inhibitory effects of disulfiram on 
rivaroxaban are unknown 
– 
Current use of warfarin 
– 
Individuals who intend to modify antiretroviral therapy during the 
study period for any reason 
– 
Significant myocardial disease (current myocarditis or reduced left 
ventricular ejection fraction below the lower limit of normal) or 
diagnosed coronary artery disease 
– 
Significant renal disease (eGFR <50mL/min)  
– 
History of psychosis, seizure disorder, abnormal 
electroencephalogram or brain damage with significant persisting 
neurological deficit  
– 
Prior malignancy active within the previous 3 years except for local 
curable cancers that have been apparently cured, such as basal or 
squamous cell skin cancer, superficial bladder cancer or carcinoma 
in situ of the prostate, cervix or breast 
– 
Known hypersensitivity to disulfiram or vorinostat or 
contraindications to treatment with these agents  
– 
Participation in another LRA study or receipt of vorinostat or 
disulfiram within the previous 12 months before starting the 
investigational treatment (visit #2) 
– 
Any significant acute medical illness requiring hospitalization within 
preceding 8 weeks  


Study Name: Combination Latency Reversing Therapy with Disulfiram plus Vorinostat in HIV Infected Individuals on antiretroviral 
therapy (ART): A Single Arm, Clinical Trial 
Protocol ID: MDS-IIS-55750 
Version & date: 4.0, Dated 17 June 2019 
Page 7 of 46 
– 
Hepatitis B or C co-infection as determined by detection of HBsAg 
or HCV RNA (Individuals with prior hepatitis infection that is now 
cleared are eligible for enrolment)  
– 
Receipt of immunomodulating agents (excluding immunization) or 
systemic chemotherapeutic agents within 28 days prior to study 
entry  
– 
Current or recent gastrointestinal disease or surgery that may 
impact the absorption of the investigational drug  
– 
Active substance use that in the opinion of the investigator will 
prevent adequate compliance with study procedures  
– 
Women who are currently pregnant or breastfeeding 
– 
WOCBP who are unwilling or unable to use an acceptable method 
of contraception to avoid pregnancy (as specified in the inclusion 
criteria) 
– 
Unable or unwilling to adhere to protocol procedures  
– 
The following laboratory values within 3 weeks before starting the 
investigational drug (lab tests may be repeated to obtain acceptable 
values before failure at screening is concluded)  
o 
Hepatic transaminases (AST or ALT) ≥3 x upper limit of normal 
(ULN)  
o 
Serum total bilirubin ≥1.5 x ULN  
o 
eGFR <50 mL/min  
o 
Haemoglobin <10.0 g/dL  
o 
Platelet count ≤100 x109/L  
o 
Absolute neutrophil count ≤1.5x109/L  
o 
Serum potassium, magnesium, phosphorus outside normal 
limits  
o 
Total calcium (corrected for serum albumin) or ionized calcium 
≤lower normal limits  
Number of Planned 
Participants: 
15 
Investigational product: 
Disulfiram (2000mg) tablets daily for 28 days (days 1 – 28) 
Vorinostat (400mg) tablets once daily on 
days 8, 9, 10 and 
days 22, 23, 24 
Statistical Methods: 
Sample size: 
The primary comparison for study is the level of plasma HIV RNA on 
day 11 during disulfiram/vorinostat treatment compared to baseline.  
Based on two previous studies of latency reversing agents (LRAs), 
where treatment with disulfiram 2000 mg or romidepsin led to increases 
in plasma HIV RNA, we assume a pre-study mean plasma HIV RNA of 
1 copy/mL and a standard deviation of 11 copies/mL.  Based on these 
numbers, the study will require 14 participants to detect an increase in 
plasma HIV RNA of 10 copies/mL with 80% power at a 0.05 significance 
level.  Targeted enrolment is 15 participants to accommodate for loss to 
follow-up.  
Analyses of primary and secondary endpoints  


Study Name: Combination Latency Reversing Therapy with Disulfiram plus Vorinostat in HIV Infected Individuals on antiretroviral 
therapy (ART): A Single Arm, Clinical Trial 
Protocol ID: MDS-IIS-55750 
Version & date: 4.0, Dated 17 June 2019 
Page 8 of 46 
The primary comparisons will be made using paired t-test or signed-
rank test as appropriate.  By applying the same statistical methods, we 
will also analyse changes in CA-US HIV RNA following administration of 
high dose disulfiram and vorinostat.  We will use repeated measurement 
analysis of variance statistics and/or generalized estimating equation 
statistics to analyse overall changes in primary and secondary 
endpoints during study intervention by including all data points during 
study therapy.  P-values <0.05 will be considered significant.  
Assessment of tolerability will include all participants who have received 
at least one dose of disulfiram.  AEs and SAEs will be summarized 
according to severity assessment showing the number and percentage 
of participants experiencing at least one event, the number of events, 
and the causality assessment.  No formal statistical comparisons will be 
made - AE rates are presented for descriptive purpose  
 
 


Study Name: Combination Latency Reversing Therapy with Disulfiram plus Vorinostat in HIV Infected Individuals on antiretroviral 
therapy (ART): A Single Arm, Clinical Trial 
Protocol ID: MDS-IIS-55750 
Version & date: 4.0, Dated 17 June 2019 
Page 9 of 46 
1. GLOSSARY OF ABBREVIATIONS & TERMS 
Abbreviation 
Description 
AE 
Adverse event 
ART 
Antiretroviral therapy 
CA-US HIV RNA 
Cell Associated Unspliced HIV RNA 
CD4+ T-cells 
White blood cells that are an essential part of the human immune 
system 
CTCL 
Cutaneous T-cell lymphoma 
DMSO 
Dimethyl sulfoxide 
DNA 
deoxyribonucleic acid 
ECG 
Electrocardiography 
eCRF 
electronic case report form 
eGFR 
estimated glomerular filtration rate 
HBsAg 
hepatitis B surface antigen 
HCV 
Hepatitis C virus 
HDAC 
Histone Deacetylase 
HDACi 
Histone Deacetylase inhibitor 
HIV 
Human Immunodeficiency virus 
HREC 
Human Research Ethics Committee 
LRA 
Latency Reversing Agents 
LTR 
HIV Long-terminal Repeat, the promotor for HIV transcription 
PBMC 
Peripheral Blood Mononuclear Cell 
PCR 
Polymerase Chain Reaction 
pK 
Pharmacokinetics 
qPCR 
quantitative Polymerase Chain Reaction 
RNA 
Ribonucleic acid  
SAE 
Serious adverse event 
SOC 
Standard of care 


Study Name: Combination Latency Reversing Therapy with Disulfiram plus Vorinostat in HIV Infected Individuals on antiretroviral 
therapy (ART): A Single Arm, Clinical Trial 
Protocol ID: MDS-IIS-55750 
Version & date: 4.0, Dated 17 June 2019 
Page 10 of 46 
Abbreviation 
Description 
SUSAR 
Suspected Unexpected Serious Adverse Reaction 
TGA 
Therapeutics Goods Administration (Australia) 
TILDA 
Tat/rev Induced Limiting Dilution Assay. 
WOCBP 
Women of Child Bearing Potential 
 
2. RESEARCHERS 
2.1 
COORDINATING PRINCIPAL INVESTIGATOR  
Professor Sharon R Lewin 
Director – The Peter Doherty Institute for Infection and Immunity, The University of Melbourne 
and Royal Melbourne Hospital 
792 Elizabeth Street 
Melbourne VIC 3000 
Australia 
Email: sharon.lewin@unimelb.edu.au 
Tel: (03) 8344 3159 
Consultant infectious diseases physician, 
Department of Infectious Diseases, Alfred Hospital and Monash University 
50 Commercial Road, 
Melbourne VIC 2004 
Australia 
2.2 
ASSOCIATE INVESTIGATORS 
Dr James McMahon 
Infectious diseases physician 
Department of Infectious Diseases, Alfred Hospital and Monash University 
50 Commercial Road, 
Melbourne VIC 3004 
Australia 
Email: james.mcmahon@monash.edu 
Tel: 0421 120 201 
Dr Thomas Aagaard Rasmussen 
Associate Clinical Director of HIV CURE Studies 
Doherty Institute 
792 Elizabeth Street 
Melbourne VIC 3000 
Australia 
Email: rasmussent@unimelb.edu.au 
Tel: (03) 8344 3501 


Study Name: Combination Latency Reversing Therapy with Disulfiram plus Vorinostat in HIV Infected Individuals on antiretroviral 
therapy (ART): A Single Arm, Clinical Trial 
Protocol ID: MDS-IIS-55750 
Version & date: 4.0, Dated 17 June 2019 
Page 11 of 46 
2.3 
COLLABORATOR 
Associate Professor Sarah Palmer 
Deputy Director, Centre for Virus Research 
Westmead Millennium Institute for Medical Research 
University of Sydney 
PO Box 412 
Westmead, NSW 2145  
Australia 
Email: sarah.palmer@sydney.edu.au 
Tel: (02) 8627 3620 
2.4 
CONTACT 
Barbara Scher 
Clinical Research Liaison Officer 
Doherty Institute 
792 Elizabeth Street 
Melbourne VIC 3000 
Australia 
Email: barbara.scher@unimelb.edu.au 
Tel: (03) 8344 0770 
3. INTRODUCTION/BACKGROUND INFORMATION 
3.1 
LAY SUMMARY 
Antiretroviral therapy (ART) dramatically reduces HIV replication leading to restoration of 
immune function and a near normal life expectancy, but treatment is lifelong and there is no 
cure.  The major barrier to a cure is the persistence of long lived CD4+ T-cells that contain a 
“silenced” form of HIV, called HIV latency. 
The purpose of this research is to investigate whether it may be possible to reduce the amount 
of dormant HIV infection in immune cells, by “turning on” or activating the virus and hence 
force it out of the latently infected memory T cells.  This leads to production of HIV by the cell, 
which will either die or will be recognised and eliminated by the immune system.  As very few 
T cells are latently infected with HIV, the death of these cells is not expected to affect the 
function of the immune system and further infection of new cells is expected to be prevented 
by ART 
This study is looking at whether taking a short course of two drugs: high dose disulfiram for 
28 continuous days with 2 intermittent 3 day courses of vorinostat (on days 8 – 10 and on 
days 22-24 of treatment) in addition to regular ART, will activate virus production from latency.  
The ultimate aim of this research is to identify a potent intervention to reverse latency that 
could then be combined with other interventions to achieve HIV remission. 
Disulfiram, (Antabuse®), is a licensed medication for the treatment of alcohol addiction.  
Disulfiram inhibits aldehyde dehydrogenase and therefore interferes with the metabolism of 
alcohol.  Alcohol is broken down in the body to a compound called acetaldehyde.  This is then 
normally broken down further by an enzyme in the liver called aldehyde dehydrogenase.  


Study Name: Combination Latency Reversing Therapy with Disulfiram plus Vorinostat in HIV Infected Individuals on antiretroviral 
therapy (ART): A Single Arm, Clinical Trial 
Protocol ID: MDS-IIS-55750 
Version & date: 4.0, Dated 17 June 2019 
Page 12 of 46 
Disulfiram stops this enzyme from working, causing an accumulation of acetaldehyde in the 
blood stream which causes unpleasant symptoms such as flushing, headaches, nausea and 
vomiting which are enough to deter people from drinking alcohol.  In the laboratory and in a 
recent clinical trial in HIV-infected individuals on ART, high dose disulfiram was shown to 
increase production of HIV from latently infected cells and therefore this drug may have a 
potential role in eliminating HIV that persists on ART.  
Vorinostat is an anti-cancer (antineoplastic or cytotoxic) drug, known as a Histone Deacetylase 
(HDAC) Inhibitor.  HDACs are enzymes normally present in cells that affects regulation of 
gene expression, which is the process by which a gene's information is converted into the 
structures and functions of a cell.  By inhibiting HDAC, vorinostat causes cancer cells to die.  
Through this mechanism Vorinostat is effective in the treatment of different types of cancer.  
Vorinostat is approved by the Australian Therapeutic Goods Administration (TGA) for the 
treatment of subcutaneous T-cell lymphoma (a type of skin cancer).  In the laboratory and in 
several clinical trials in HIV-infected individuals on ART, vorinostat was shown to increase 
production of HIV from latently infected cells and therefore this drug may have a potential role 
in eliminating HIV that persists on ART.  Both disulfiram and vorinostat are not approved by 
the TGA for the treatment of HIV. 
This study involves study participants to attend the clinic at the Alfred hospital approximately 
9 times over a 6 month period to attend specific study visits.  These visits will take place at 
screening, baseline (day 0), days 8, 11, 22, 25, 28, 56 and 196 (month 6). 
Study participants will be enrolled after all the inclusion criteria are met.  During the course of 
the study, the investigators will meet regularly to monitor study progress and participant safety 
by reviewing all information, including side effects.   
3.2 
INTRODUCTION 
One strategy aimed at reducing the frequency of latently infected cells in HIV-infected 
individuals on antiretroviral therapy (ART) is the use of pharmacological agents to reverse HIV 
latency, thereby initiating virus-mediated cell lysis or immune-mediated killing1.  Recent clinical 
trials of latency reversing agents (LRAs) in HIV infected subjects on ART, including histone 
deacetylase inhibitors (HDACi)2-4 and the anti-alcoholism drug disulfiram5,6, have shown that 
inducing an increase in CA-US or plasma HIV RNA is possible.  Yet, these interventions did 
not have a demonstrable effect on the frequency of latently infected cells or time to viral 
rebound after cessation of ART3, potentially because latency reversal alone didn’t trigger an 
adequate immune response or cell death or that the potency of latency reversal with a single-
agent intervention over a very short period of time, lacked sufficient potency, as suggested by 
recent in vitro studies7.  It is highly likely that long term remission off ART will require 
interventions that lead to both a reduction in latently infected cells and an increase in HIV-
specific immunity, therefore identifying a strategy to increase viral antigens on the surface of 
latently infected cells will be a key component of this strategy.  Here we propose a single-arm 
clinical trial of high-dose disulfiram together with intermittent administration of the HDACi 
vorinostat in HIV-infected individuals on ART as a strategy to increase potency of latency 
reversal with low risk of increased toxicity 


Study Name: Combination Latency Reversing Therapy with Disulfiram plus Vorinostat in HIV Infected Individuals on antiretroviral 
therapy (ART): A Single Arm, Clinical Trial 
Protocol ID: MDS-IIS-55750 
Version & date: 4.0, Dated 17 June 2019 
Page 13 of 46 
3.3 
BACKGROUND INFORMATION 
There are multiple factors that lead to the establishment and maintenance of HIV latency8. 
These include the low availability of key transcription factors in resting CD4+ T cells9 as well 
as the chromatin environment of the integrated provirus leading to transcriptional silencing or 
interference8.  HDACi increase histone acetylation, which promotes initiation of HIV 
transcription, but additional blocks in RNA splicing, RNA export and low availability of cellular 
transcription factors may limit the efficiency of virus production10.  It is plausible that targeting 
several latency mechanisms will enhance the expression of viral proteins or production of free 
virions in latently infected resting CD4+ T cells. 
When resting CD4+ T cells from HIV-infected individuals on suppressive ART were exposed 
to combinations of LRAs ex vivo, there was a synergistic increase in HIV production, in some 
cases approaching that of maximal T cell activation11.  The most striking synergy was seen 
with combinations of potent HDACis such as romedepsin and the protein kinase C (PKC) 
agonist bryostatin-1, but their associated toxicities may not allow for clinical co-administration.  
Other combinations that are more feasible in the clinical setting, also showed at least additive 
effects in vitro.  For example, in contrast to either drug alone, the combination of HDACi and 
disulfiram consistently increased levels of intracellular HIV RNA relative to DMSO (dimethyl 
sulfoxide) controls ex vivo11.  Synergy analyses indicated that HDACi and disulfiram reverse 
HIV latency by independent mechanisms11.  Whereas HDACi reverse HIV latency by 
promoting histone acetylation and chromatin relaxation12, disulfiram activates HIV 
transcription by depletion of phosphatase and tensin homolog (PTEN), which alleviates 
inhibition of the Akt signalling pathway.  Activated Akt phosphorylates hexamethylene bis-
acetamide inducible 1 (HEXIM1), which subsequently causes release of positive transcription 
elongation factor b (p-TEFb) to enhance HIV transcription.  P-TEFb is otherwise only present 
at very low levels in resting CD4+ T cells13. 
Safety and efficacy of disulfiram and vorinostat as LRAs in vivo 
Disulfiram and vorinostat have both been shown to increase HIV transcription in vitro14-16 and 
in clinical trials2,6,17.  With its long-standing use to treat alcoholism, favourable tolerability and 
lack of mutagenic potential, disulfiram can be administered for extended periods.  Vorinostat 
(Zolinza®), is a pan HDAC inhibitor18 with regulatory approval for the treatment of cutaneous 
T cell lymphoma.  Although less potent than the more recently licensed HDACi panobinostat 
and romidepsin, vorinostat has the advantage of being orally administered and has an 
extensive safety profile.  In vitro, compared to other HDACi, vorinostat had minimal effects on 
suppressing HIV-specific T-cell function, in contrast to romidepsin which potently suppressed 
T-cell function19.  Finally, we previously showed that vorinostat has acceptable tolerability 
during daily dosing for 14 days, which led to increases in HIV transcription in ART-suppressed 
HIV patients in blood and in rectal tissue and no adverse effects on HIV-specific T-cells in 
vivo2.  In addition, long term follow up of these participants for two years demonstrated no 
adverse clinical or virological effects of vorinostat in HIV-infected individuals on ART [Mota, 
submitted]. 
Here we propose to administer disulfiram at 2g/day for 28 days with two additional short 
courses of vorinostat.  The rationale here is to give an LRA for a prolonged period alone and 
in combination.  Disulfiram is the only LRA that has an appropriate toxicity profile, which would 
allow for prolonged administration.  Based on our experience with two clinical studies of 
disulfiram in HIV infection given at standard dose (500mg/day) for 14 days5 and at high dose 


Study Name: Combination Latency Reversing Therapy with Disulfiram plus Vorinostat in HIV Infected Individuals on antiretroviral 
therapy (ART): A Single Arm, Clinical Trial 
Protocol ID: MDS-IIS-55750 
Version & date: 4.0, Dated 17 June 2019 
Page 14 of 46 
(1 and 2 g/day) for 3 days6, we believe that administration at 2g/day for 28 days is safe and 
feasible.  Previously, disulfiram was used in the clinical setting at relatively high doses ranging 
from 1-3 g20 and up to 6g21 in individuals with alcoholism, and was generally reported to be 
safe with the most significant safety concern being fatal disulfiram-induced hepatitis, which is 
estimated to occur extremely rarely at 1 per 25,000 patients treated/year20.   
In addition, vorinostat will be administered on two occasions for 3 days each.  In our study of 
14 days of vorinostat, we observed maximal increase in both histone acetylation and US RNA 
after 8-24 hours of the initial dose and minimal adverse events2.  With repeated vorinostat 
dosing, we saw no evidence of a refractory response to vorinostat but a sustained increase in 
US RNA up to 84 days following repeated administration2, however, others have reported a 
potential suppression of the effects of vorinostat after at least 4 courses of 3 days of 
vorinostat22.  By administering vorinostat as two separate courses in this study, we will reduce 
the possibility of a refractory response.  Furthermore, in this study we can assess whether 
addition of vorinostat after 7 days of disulfiram will lead to higher increases in plasma HIV RNA 
relative to disulfiram alone (first seven days of study) or if potential “priming” is occurring 
leading to an enhanced response after a second administration of 3 days of vorinostat. 
It remains unclear whether the sequence of these two LRAs will have an impact on the potency 
of latency reversal.  Most in vitro studies that have assessed combination latency reversal 
have administered the two agents concurrently11,29,30,31.  In this study, we believe the initial 
administration of disulfiram for 7 days prior to administration of vorinostat will provide 
additional information of the effects of high dose disulfiram that was not addressed in previous 
studies6. 
In conclusion, combinations of LRAs that target different pathways that maintain HIV latency 
may significantly enhance the potency of latency reversal.  As disulfiram and vorinostat have 
already been evaluated alone in HIV-infected individuals on ART, have additive effects on HIV 
transcription in vitro and ex vivo and have acceptable safety profiles, the combination of these 
two drugs is ideally suited for the first combination LRA study to be performed in HIV-infected 
individuals on ART. 
4. STUDY OBJECTIVES 
4.1 
HYPOTHESES  
4.1.1 Primary hypothesis:  
Administration of 28 days of disulfiram with intermittent administration of 3 days of vorinostat 
will reverse HIV latency in HIV infected patients on ART as measured by plasma HIV RNA.  
4.1.2 Secondary hypothesis:  
Latency reversal with 28 days of disulfiram and intermittent administration of 3 days of 
vorinostat on two occasions will reduce the frequency of latently infected CD4+ T cells through 
virus- or immune-mediated cell lysis. 


Study Name: Combination Latency Reversing Therapy with Disulfiram plus Vorinostat in HIV Infected Individuals on antiretroviral 
therapy (ART): A Single Arm, Clinical Trial 
Protocol ID: MDS-IIS-55750 
Version & date: 4.0, Dated 17 June 2019 
Page 15 of 46 
4.2 
OBJECTIVES 
4.2.1 Primary efficacy objective: 
To determine the effect of 28 days of disulfiram with intermittent administration of 3 days of 
vorinostat on two occasions on plasma HIV RNA in HIV infected individuals on suppressive 
ART. 
4.2.2 Primary safety objective: 
To determine the tolerability of 28 days of disulfiram with intermittent administration of 3 days 
of vorinostat on two occasions in HIV infected individuals on suppressive ART. 
4.2.3 Secondary objective: 
To determine the effect of 28 days of disulfiram with intermittent administration of 3 days of 
vorinostat on two occasions on the frequency of latently infected CD4+ T cells in HIV infected 
individuals on suppressive ART. 
4.3 
OUTCOME MEASURES 
4.3.1 Primary endpoint  
– Plasma HIV RNA on day 11 relative to baseline  
4.3.2 Secondary endpoints  
– 
Tolerability as measured by the incidence and severity of adverse events  
– Plasma HIV RNA relative to baseline at additional time points  
– HIV transcription measured by cell-associated unspliced HIV RNA (CA-US HIV RNA) 
in peripheral blood CD4+ T cells relative to baseline 
– Cell-associated total and integrated HIV DNA in peripheral blood CD4+ T cells relative 
to baseline 
– The frequency of inducible virus as measured by Tat/rev limiting dilution assay (TILDA) 
in peripheral blood CD4+ T cells relative to baseline 
– 
Concentrations of vorinostat and disulfiram (including its metabolites) in plasma  
– 
p24 expression in CD4+ T-cells relative to baseline 
5. STUDY DESIGN 
5.1 
STUDY SITES 
Study participants will be enrolled at one site: 
- 
The Department of Infectious Diseases, Alfred Hospital, Melbourne 
Laboratory support for the virological and immunological assays will be performed at three 
sites: 
- 
Lewin/Cameron Laboratory, The Peter Doherty Institute for Infection and Immunity, 
The University of Melbourne 
- 
Infectious disease and vaccines department, Merck (specifically p24 expression in 
PBMCs) 


Study Name: Combination Latency Reversing Therapy with Disulfiram plus Vorinostat in HIV Infected Individuals on antiretroviral 
therapy (ART): A Single Arm, Clinical Trial 
Protocol ID: MDS-IIS-55750 
Version & date: 4.0, Dated 17 June 2019 
Page 16 of 46 
- 
Centre for Virus Research, The Westmead Institute for Medical Research 
5.2 
STUDY DESIGN 
This is a single arm, dual site, clinical trial in HIV-infected patients on suppressive ART with a 
before-after design (figure 1).  Targeted enrolment is 15 study participants.  All enrolled study 
participants will receive treatment with 
– Disulfiram 2000mg once daily for 28 days (days 1 - 28), plus 
– Vorinostat (400mg, once daily) given on days 8, 9 10 and 22, 23 and 24.  Total of 6 
days. 
The duration of study therapy is 28 days. 
Figure 1. Study design and sampling schedule 
 
 
 
 
 
 
        
 
0 
    1 
  2 
    3 
 4 
 8 
 
       28 Weeks 
5.3 
APPROXIMATE DURATION OF STUDY PARTICIPATION 
Study participants will be in the study for up to 203 days.  The duration of participation is 
calculated from the initial screening visit (visit #1) to the last study visit (visit #9) using the first 
and last day, respectively, of those visit windows. 
5.4 
APPROXIMATE DURATION OF THE STUDY 
The study will be completed in approximately 12 months.  The end of the study is defined as 
last patient enrolled last visit. 
5.5 
SOURCE DATA 
The following documents are defined as source data: 
– Patient (medical) charts 
– Print outs of biochemical, immunological and virological measurements from Alfred 
Health Pathology/Clinical Biochemistry/Clinical Immunology laboratories 
– Alcohol questionnaire.  The study participant will enter answers directly into the 
electronic questionnaire within the database.  There will be no paper copy.  The 
database will date and time stamp when the questionnaire was started.  A copy of the 
completed questionnaire will be made available to the site, by the sponsor as per GCP 
requirement section 4.9.2. 
– 
Direct results from other laboratory analyses performed during the study (including and 
not limited to) 
o Cell-associated US HIV-RNA 
Disulfiram 2000mg daily 
Screening 
HIV-1 infection 
On ART 
VL <50/mL for > 3 
years 
CD4 > 350/µ 
 Blood Draw 
Vorinostat 400 mg 


Study Name: Combination Latency Reversing Therapy with Disulfiram plus Vorinostat in HIV Infected Individuals on antiretroviral 
therapy (ART): A Single Arm, Clinical Trial 
Protocol ID: MDS-IIS-55750 
Version & date: 4.0, Dated 17 June 2019 
Page 17 of 46 
o Cell associated total and integrated HIV-DNA analyses 
o Low-level viremia (single copy assay) 
o 2-LTR analysis 
o Flow cytometry data 
o Soluble biomarker measurements 
o p24 expression in PBMC’s 
– For the following information, site worksheets may contain the following source data: 
o Date of birth, gender, ethnicity, study ID number 
o Anthropometric data and vital signs 
o Brief medical history, including list of medical conditions 
o List of concomitant medications 
o Signs and symptoms noted by a medical examination 
o AE reporting sheet (including SAE and SUSAR) 
6. STUDY POPULATION 
6.1 
RECRUITMENT PROCEDURE 
Fifteen (15) HIV-infected individuals on long term ART will be enrolled into the study. 
Potential participants will be recruited by a direct approach to clinic patients by study personnel 
at the treating centre and through advertising the study in regular and social media outlets.  
Initially, potential participants will be identified by reviewing lists of upcoming clinic patient 
visits and potential participants will be “pre-screened” to establish whether they meet the 
inclusion/exclusion criteria of the study.  If the clinician caring for the potential participant is 
not a study investigator then the research staff (research co-ordinators or investigators) will 
seek permission from the clinician prior to any contact with the potential participant.  If the 
caring clinician agrees then, the research staff will contact the study participant or meet with 
them to see if they would be interested in participating in the study. 
Any drug which contains, or may contain, alcohol will not be allowed in the study, due to the 
action of disulfiram.  The liquid and/or gelatin capsule formulations of ritonavir and 
lopinavir/ritonavir contain alcohol.  The liquid formulation of ritonavir is 42% alcohol, and the 
gelatin capsule formulation is 12% alcohol.  Notably, the more popular heat-stable tablet 
formulations of ritonavir and lopinavir/ritonavir do not contain appreciable levels of alcohol and 
hence will be allowed in this study.  Individuals receiving liquid or gelatin forms of ritonavir or 
lopinavir/ritonavir will be informed that their primary care provider will need to change these 
drugs to a heat stable tablet formulation prior to screening.  Certain formulations of amprenavir 
contain alcohol and hence this drug will also not be allowed in this study. 
The pharmacology of tipranvavir is complex and difficult to predict in the absence of formal 
pharmacokinetic studies.  The toxicity associated with excess exposure to this drug can be 
significant. We will therefore exclude individuals receiving this drug. Maraviroc is metabolized 
via the P450 system and has to be dose adjusted when given with ritonavir.  Maraviroc may 
have immunomodulatory effects that could affect the activity of disulfiram.  For these reasons, 
we will exclude individuals receiving maraviroc.  There are no expected drug interactions 


Study Name: Combination Latency Reversing Therapy with Disulfiram plus Vorinostat in HIV Infected Individuals on antiretroviral 
therapy (ART): A Single Arm, Clinical Trial 
Protocol ID: MDS-IIS-55750 
Version & date: 4.0, Dated 17 June 2019 
Page 18 of 46 
between disulfiram and most of the other commonly used antiretroviral drugs, including the 
integrase inhibitors, dolutegravir, elvitegravir and raltegravir. 
6.2 
INCLUSION CRITERIA  
- 
Age 18 years or older with documented HIV-1 infection (antibody positive or detectable 
plasma HIV-1 RNA) 
- 
Receiving combination ART with plasma HIV RNA <50 copies/mL for >3 years 
- 
CD4+ T cell count >350/uL at screening 
- 
Able to provide informed consent 
- 
Willing to abstain from alcohol consumption from one day before to 14 days after 
completing 28 days of disulfiram 
- 
One month post influenza vaccine (from screening visit) 
- 
Women of non-child-bearing potential defined as: 
o > 12 months of spontaneous amenorrhea and ≥ 45 years of age, or 
o Documented medical history of one of the following: hysterectomy, bilateral 
oophorectomy or tubal ligation. 
- 
Women of Child Bearing Potential (WOCBP) with a negative pregnancy test at 
Screening (visit #1) and agrees to use one of the following methods of contraception 
to avoid pregnancy: 
o Complete abstinence from penile-vaginal intercourse from 2 weeks prior to 
administration of IP, throughout the study and for at least 2 weeks after 
discontinuation of all study medications 
o Double barrier method (male condom/spermicide, male condom/diaphragm, 
diaphragm/spermicide) 
o Any intrauterine device (IUD) with published data showing that the expected 
failure rate is <1% per year 
o Male partner sterilization confirmed prior to the female subject’s entry into 
the study, and this male is the sole partner for that subject 
o Approved hormonal contraception (Where other medications to be used in the 
study (e.g., efavirenz and darunavir) are known, or are likely, to significantly 
interact with systemic contraceptives, resulting in decreased efficacy of the 
contraceptive, then alternative methods of non-hormonal contraception are 
recommended) 
o Any other method with published data showing that the expected failure rate is 
<1% per year 
Any contraception method must be used consistently, in accordance with the approved 
product label and for at least 2 weeks after discontinuation of study therapy.   
6.3 
EXCLUSION CRITERIA  
– 
Current alcohol use disorder or hazardous alcohol use (>7 drinks per week for 
women or > 14 drinks per week for men) as determined by clinical evaluation 
– 
Current or recent (in the last 4 days) use of metronidazole or any drug formulation 
that contains alcohol or that might contain alcohol, including the gelatin capsule and 
liquid formulations of ritonavir, ritonavir/lopinavir, amprenavir and fosamprenavir, 


Study Name: Combination Latency Reversing Therapy with Disulfiram plus Vorinostat in HIV Infected Individuals on antiretroviral 
therapy (ART): A Single Arm, Clinical Trial 
Protocol ID: MDS-IIS-55750 
Version & date: 4.0, Dated 17 June 2019 
Page 19 of 46 
and alcohol-containing preparations such as cough syrups, tonics etc. 
– 
Current use of tipranavir or Maraviroc 
– 
Current use of zidovudine, stavudine or didanosine (as disulfiram potentially has 
potent irreversible inhibitory effects on mitochondrial metabolism and hence could 
exacerbate the toxicity of these drugs) 
– 
Concurrent use of rivaroxaban (a CYP3A metabolized medication) as the cytochrome 
P450 inhibitory effects of disulfiram on rivaroxaban are unknown 
– 
Current use of warfarin 
– 
Individuals who intend to modify antiretroviral therapy during the study period for any 
reason 
– 
Significant myocardial disease (current myocarditis or reduced left ventricular ejection 
fraction below the lower limit of normal) or diagnosed coronary artery disease 
– 
Significant renal disease (eGFR <50mL/min) 
– 
History of psychosis, seizure disorder, abnormal electroencephalogram or brain 
damage with significant persisting neurological deficit 
– 
Prior malignancy active within the previous 3 years except for local curable cancers 
that have been apparently cured, such as basal or squamous cell skin cancer, 
superficial bladder cancer or carcinoma in situ of the prostate, cervix or breast. 
– 
Known hypersensitivity to disulfiram or vorinostat or contraindications to treatment 
with these agents 
– 
Participation in another LRA study or receipt of vorinostat or disulfiram in the previous 
12 months before starting the investigational treatment (visit #2) 
– 
Any significant acute medical illness requiring hospitalization within preceding 8 
weeks 
– 
Hepatitis B or C co-infection as determined by detection of HBsAg or HCV RNA 
(Individuals with prior hepatitis infection that is now cleared are eligible for enrolment) 
– 
Receipt of immunomodulating agents (excluding immunization) or 
systemic 
chemotherapeutic agents within 28 days prior to study entry 
– 
Current or recent gastrointestinal disease or surgery that may impact the absorption 
of the investigational drug 
– 
Active substance use that in the opinion of the investigator will prevent adequate 
compliance with study procedures 
– 
Women who are currently pregnant or breastfeeding 
– 
Women of Child Bearing Potential (WOCBP) who are unwilling or unable to use an 
acceptable method of contraception to avoid pregnancy (as specified in the inclusion 
criteria, section 6.2) 
– 
Unable or unwilling to adhere to protocol procedures 
– 
The following laboratory values within 6 weeks before starting the investigational 
drug (lab tests may be repeated to obtain acceptable values before failure at 
screening is concluded) 
o Hepatic transaminases (AST or ALT) ≥3 x upper limit of normal (ULN) 
o Serum total bilirubin ≥1.5 x ULN 
o eGFR <50 mL/min 
o Haemoglobin <10.0 g/dL 
o Platelet count ≤100 x109/L 


Study Name: Combination Latency Reversing Therapy with Disulfiram plus Vorinostat in HIV Infected Individuals on antiretroviral 
therapy (ART): A Single Arm, Clinical Trial 
Protocol ID: MDS-IIS-55750 
Version & date: 4.0, Dated 17 June 2019 
Page 20 of 46 
o Absolute neutrophil count ≤1.5x109/L 
o Serum potassium, magnesium, phosphorus outside normal limits 
o Total calcium (corrected for serum albumin) or ionized calcium ≤ lower normal 
limits 
6.4 
WITHDRAWAL FROM THE STUDY 
Withdrawal from study is defined as any participant included in the study who does not 
complete the final follow-up visit defined in this protocol. 
Reasons why a study participant may be withdrawn from the study include, but are not limited 
to: 
– 
Participant request (withdrawal of consent) 
– Protocol violation 
– Adverse events or reactions 
– Pregnancy 
– Any condition, interaction, or contraindication where continued participation in the 
study will result in an unacceptable risk for the participant, as assessed by the 
investigators  
– Discontinuation of the study by the Sponsor 
– Lost to follow-up 
Investigator will contact study participants who fail to return for planned visits and if possible 
schedule a new visit.  Information related to study withdrawal is documented in the eCRF (End 
of Study) including the reason for withdrawal, date of withdrawal, and whether the participant 
or investigator made this decision.  If withdrawal from the study is due to an adverse event, 
this will be followed up as detailed under adverse event reporting in this protocol.  
Participants withdrawn from the study will resume routine treatment at the Department of 
Infectious Diseases, Alfred Hospital or their normal site of HIV care following standard 
treatment guidelines. 
6.5 
WITHDRAWAL FROM THE INVESTIGATIONAL DRUG(S) 
Withdrawal from the investigational drug(s) is defined as any participant who discontinues 
study treatment but agrees to a modified follow-up until completion of the study.  Any 
participant who withdraws from the investigational drug after having received at least one dose 
will be asked to return for a follow-up visit 1 week after withdrawal from the study treatment 
(safety monitoring) and the final follow-up visit as described in this protocol.  
Reasons why a study participants may be withdrawn from the investigational drug(s) include, 
but are not limited to: 
– Participant request (withdrawal of consent) 
– Adverse events or reactions 
– Pregnancy 
– Any condition, interaction, or contraindication where continued participation in the 
study will result in an unacceptable risk for the participant, as assessed by the 
investigators. 


Study Name: Combination Latency Reversing Therapy with Disulfiram plus Vorinostat in HIV Infected Individuals on antiretroviral 
therapy (ART): A Single Arm, Clinical Trial 
Protocol ID: MDS-IIS-55750 
Version & date: 4.0, Dated 17 June 2019 
Page 21 of 46 
Information related to withdrawal from the investigational drug/placebo is documented in the 
eCRF (End of Study) including the reason for withdrawal, date of withdrawal, and whether the 
participant or investigator made this decision.  If withdrawal from the investigational 
drug/placebo is due to an adverse event, this will be followed up as detailed under adverse 
event report in this protocol.  
Participants withdrawn from the investigational drug(s) will resume routine treatment and 
monitoring at either the Department of Infectious Diseases, Alfred Hospital, Melbourne. 
6.6 
REPLACEMENTS 
A participant is defined as included in the study when he or she has signed consent and 
completed the screening visit.  Any exclusion or withdrawal from the study prior to baseline 
will be defined as failure at screening. 
Participants withdrawn from the study before receipt of investigational drug will be replaced.  
Participants who withdraw from the study after receipt of the investigational drug(s) will have 
the potential to be replaced if the investigators assess that the outcome measures of the trial 
cannot be adequately assessed.  Any decision on replacement of such individuals will be by 
consensus of the principal and associate investigators on a case by case basis. 
7. STUDY TREATMENT 
7.1 
INVESTIGATIONAL DRUGS 
The investigational drugs administered in this study are disulfiram and vorinostat. 
7.1.1 Disulfiram 
Disulfiram (ANTABUSE®), is a sulphydryl (-SH, thiol) group reagent and inhibits enzymes 
concerned with oxidation of active (-SH group) sites on enzyme protein molecules.  The 
pharmacological action of disulfiram is based on its inhibition of enzymes involved in ethanol 
catabolism.  Normally, ethanol is metabolised to carbon dioxide and water but, in the presence 
of disulfiram, the enzyme aldehyde dehydrogenase is inhibited and the metabolic chain of 
reactions stop after the production of acetaldehyde.  Although it is accepted that acetaldehyde 
accumulation produces the disulfiram-ethanol reaction, it is also believed that the reaction may 
be caused by a toxic quaternary compound. 
Disulfiram is TGA approved to act as a deterrent to alcohol consumption and an aid in the 
overall management of selected chronic alcoholic patients involved in an integrated 
programme of counselling and psychiatry. 
Disulfiram is not approved by the TGA for use in the treatment of HIV infection in adults. 
7.1.2 Vorinostat 
Vorinostat (Zolinza®), is a pan HDAC inhibitor18 with T G A  approval for the treatment of 
cutaneous T cell lymphoma.  Although less potent than the more recently licensed HDACi 
panobinostat and romidepsin, vorinostat has the advantage of being orally administered and 
has an extensive safety profile. In vitro, compared to other HDACi, vorinostat had minimal 
effects on T-cell function, in contrast to romidepsin which potently suppressed T-cell 


Study Name: Combination Latency Reversing Therapy with Disulfiram plus Vorinostat in HIV Infected Individuals on antiretroviral 
therapy (ART): A Single Arm, Clinical Trial 
Protocol ID: MDS-IIS-55750 
Version & date: 4.0, Dated 17 June 2019 
Page 22 of 46 
function19.  In previous studies, vorinostat has acceptable tolerability during daily dosing for 
14 days, which led to increases in HIV transcription in ART-suppressed HIV patients in blood 
and in rectal tissue and no adverse effects on HIV-specific T-cells in vivo2. 
Vorinostat has not been approved by the TGA for the treatment of HIV infection in adults. 
7.2 
STUDY DOSE AND DURATION OF STUDY THERAPY 
In this study, all participants will receive the same study regimen – 2000mg disulfiram (4 x 
500mg tablets) administered per day continuously for a total of 28 days.  Disulfiram is 
the only LRA currently studied in people with HIV that has an appropriate toxicity profile, which 
would allow for prolonged administration.  By administering an LRA for a prolonged period 
it is hypothesized that sustained increases in plasma HIV RNA is possible and this may be 
associated with enhanced depletion of infected HIV cells.   
In addition to the disulfiram, all study participants will receive 400 mg vorinostat (4 x 
100mg) daily on two occasions for 3 days each: days 8 – 10 and days 22 - 24.  By 
administering vorinostat as two separate courses in this study, we will reduce the possibility 
of a refractory response as described above.  
Both study drugs will be provided free of charge to the study participants. 
7.3 
DRUG SUPPLIES AND ADMINISTRATION 
7.3.1 Disulfiram 
Disulfiram will be purchased by the Alfred Pharmacy, on behalf of the sponsor, through their 
supplier Medsurge for this study.  The drug product is manufactured for TEVA 
pharmaceuticals.  The study drug will be provided as an white, round scored tablet containing 
500mg disulfiram.  For further details on the physical, chemical and pharmaceutical properties, 
refer to the product information  
7.3.2 Vorinostat 
Merck will supply the investigational drug vorinostat.  The drug product provided is film –coated 
oral tablets containing 100mg vorinostat.  The tablets are packaged into high-density 
polyethylene (HDPE) bottles with child-resistant closures that include induction seals.  For 
further details on the physical, chemical and pharmaceutical properties, refer to the product 
information TGA website 
(https://www.ebs.tga.gov.au/ebs/picmi/picmirepository.nsf/pdf?OpenAgent&id=CP-2010-PI-
01481-3&d=2017010316114622483).  The drug will be provided to the Alfred pharmacy in 4 
bottles, which will be labelled as investigational product in accordance with current guidelines 
and applicable regulatory requirements. 
7.3.2 Drug Administration 
The Alfred Hospital Clinical Trials Pharmacy is responsible for receiving, storage and 
dispensing of the investigational drugs.  The clinical trials pharmacist(s) will maintain logs of 
all investigational drugs received from the manufacturer(s) and also keep accurate logs of 
investigational drugs dispensed to study participants. 


Study Name: Combination Latency Reversing Therapy with Disulfiram plus Vorinostat in HIV Infected Individuals on antiretroviral 
therapy (ART): A Single Arm, Clinical Trial 
Protocol ID: MDS-IIS-55750 
Version & date: 4.0, Dated 17 June 2019 
Page 23 of 46 
7.4 
DRUG STORAGE AND DRUG ACCOUNTABILITY 
The Alfred Hospital Clinical Trials Pharmacy is responsible for the secure and correct storage 
of the investigational drugs.  The investigational drug will be clearly marked and stored in a 
locked medicine storage in the Alfred Clinical Trials Pharmacy at room temperature.  Unused 
drug will be destroyed and disposed of pursuant to the ICH/GCP guidelines and Institutional 
policies. 
7.5 
COMPLIANCE 
The investigational drug disulfiram for the entire study duration will be provided to study 
participants in the research clinic at the commencement of study therapy day 0 (visit #2).  
Enough investigational study drug Vorinostat will be provided for 3 days on day 8 and day 22 
of the study.  At all follow-up visits, participants will be counselled to maintain adherence with 
study therapy, concomitant therapy and other study procedures.  For each participant, any 
remaining tablets of the investigational drug will be accounted for at the end of study therapy. 
7.6 
CONCOMITANT MEDICATION(S) 
Study participants are required to continue their ART regimen while receiving the 
investigational drug(s).  Any changes in anti-retroviral therapy during the study will be recorded 
in either the hospital/clinic notes or site worksheet.  Any other concomitant medical therapy 
either recorded at study entry or initiated during the study will be recorded in either the 
hospital/clinic notes or site worksheets. 
7.7 
CONCOMITANT THERAPY ALLOWED DURING THE STUDY 
Any treatment that is considered necessary for the participant’s welfare (including supportive 
therapy) and which, in the opinion of the investigator, will not interfere with the study therapy, 
may be given at the discretion of the investigator.  Specifically, vaccines that are part of a 
recommended immunization schedule or used in the event of a disease outbreak are allowed 
during study therapy. 
7.8 
CONCOMITANT THERAPY PROHIBITED DURING THE STUDY 
− 
Other investigational drugs, agents or medical devices 
− 
Use of use of metronidazole or any drug formulation that contains alcohol or that might 
contain alcohol, including the gelatin capsule and liquid formulations of ritonavir, 
ritonavir/lopinavir, amprenavir and fosamprenavir 
− 
Avoid alcohol-containing preparations such as cough syrups, sauces, vinegar, tonics, 
foods prepared with wine, after shave lotions and alcoholic back rubs. 
− 
Use of tipranavir or Maraviroc 
− 
Use of zidovudine, stavudine or didanosine  
− 
Use of rivaroxaban (a CYP3A metabolized medication) as the cytochrome P450 
inhibitory effects of disulfiram on rivaroxaban are unknown 
− 
Use of warfarin  


Study Name: Combination Latency Reversing Therapy with Disulfiram plus Vorinostat in HIV Infected Individuals on antiretroviral 
therapy (ART): A Single Arm, Clinical Trial 
Protocol ID: MDS-IIS-55750 
Version & date: 4.0, Dated 17 June 2019 
Page 24 of 46 
Initiation of any of the above medical products will necessitate withdrawal from the 
investigational drugs.  
8. STUDY PROCEDURES 
8.1 
SCHEDULE OF ACTIVITIES 
A total of 9 visits including one screening and one baseline visit will be performed during the 
study.  All study visits will occur in the morning and the time of visits will always be recorded.  
A full schedule of activities is provided below: 
Table 1: Schedule of assessments 
Visit # 
1 
screening 
2 
baseline 
3 
4 
5 
6 
7 
EOT 
8 
9 
EOS 
Days relative to starting study 
therapy 
-42 to 0 
days 
pre-
study 
therapy 
1 
pre-
study 
therapy 
8 
11 
22 
25 
28 
56 ± 7 196 ± 
10 
Study activities 
Informed consent 
X 
 
 
 
 
 
 
 
 
Medical history (incl/excl 
criteria) 
X 
X 
 
 
 
 
 
 
 
Vital signs (includes weight) 
X 
(+ height for 
this visit only) 
X 
X 
X 
X 
X 
X 
X 
X 
Clinical review 
X 
(+ physical 
examination 
for this visit 
only 
X 
X 
X 
X 
X 
X 
 
X 
Alcohol Questionnaire 
X 
 
 
 
 
 
 
 
 
Concomitant 
medication review 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Adverse event review 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Study drug administration - 
Disulfiram 
 
X 
Day 0 - 28 
 
 
 
 
 
 
 
Study drug administration - 
Vorinostat 
 
 
X 
Days 8 - 
10 
 
X 
Days 22 
- 24 
 
 
 
 
Pathology 
Haematology (FBE) 
X 
 
X 
X 
X 
 
X 
 
X 
Clinical biochemistry 
(renal function, liver enzymes, 
electrolytes) 
X 
 
X 
X 
X 
 
X 
 
X 
Pregnancy test 
(WOCBP only) 
X 


Study Name: Combination Latency Reversing Therapy with Disulfiram plus Vorinostat in HIV Infected Individuals on antiretroviral 
therapy (ART): A Single Arm, Clinical Trial 
Protocol ID: MDS-IIS-55750 
Version & date: 4.0, Dated 17 June 2019 
Page 25 of 46 
Visit # 
1 
screening 
2 
baseline 
3 
4 
5 
6 
7 
EOT 
8 
9 
EOS 
Days relative to starting study 
therapy 
-42 to 0 
days 
pre-
study 
therapy 
1 
pre-
study 
therapy 
8 
11 
22 
25 
28 
56 ± 7 196 ± 
10 
Hep C Ab and HBsAg 
X 
CD4 and CD8 counts 
X 
X 
X 
Plasma HIV RNA 
(commercial assay) 
X* 
 
 
 
 
 
X 
 
Study Specific Specimens 
Plasma HIV RNA (SCA) 
X 
X 
X 
X 
X 
X 
X 
X 
X 
CA-US HIV RNA 
X 
X 
X 
X 
X 
X 
X 
X 
X 
p24 expression 
X 
X 
X 
X 
X 
X 
X 
X 
X 
HIV DNA 
X 
X 
 
 
 
 
 
X 
X 
TILDA 
X 
X 
Plasma vorinostat and 
disulfiram 
 
X 
X 
X 
X 
X 
X 
X 
X 
Plasma and PBMC 
storage 
X 
X 
X 
X 
X 
X 
X 
X 
X 
PAX gene tube 
 
X 
X 
X 
 
X 
 
 
X 
Blood Tubes required 
ACD Tubes (10 mL) 
5 
8 
5 
5 
5 
5 
5 
8 
6 
SST Tube (3.5 mL) 
1 
1 
1 
1 
1 
1 
1 
1 
1 
K2EDTA Tube (4 mL) 
1 
1 
1 
1 
1 
1 
1 
1 
1 
PAXgene tube (3 mL) 
0 
1 
1 
1 
0 
1 
0 
0 
1 
Total volume (mL) 
57.5 
90.5 
60.5 
60.5 
57.5 
60.5 
57.5 
87.5 
 
* - only to be performed if the test was not ordered as part of standard of care in the previous 
3 months. 
8.2 
VISIT 1 – SCREENING 
This screening visit must occur within the preceding 42 days of initiating study therapy.  
However, screening lab tests taken as part of standard of care with 84 days of study baseline 
(visit 2) can be used to assess eligibility.   
− 
Signed informed consent prior to any study related procedures, 
− 
Demographics 
− 
Medical History 
− 
Document HIV history including date of diagnosis, antiretroviral therapy and HIVRNA 
results 
− 
Complete physical examination, including height and weight.  After the participant 
signs consent, any new events/findings not present in the participant’s medical history 
or is a worsening side effect should be recorded as adverse events in the eCRF. 


Study Name: Combination Latency Reversing Therapy with Disulfiram plus Vorinostat in HIV Infected Individuals on antiretroviral 
therapy (ART): A Single Arm, Clinical Trial 
Protocol ID: MDS-IIS-55750 
Version & date: 4.0, Dated 17 June 2019 
Page 26 of 46 
− 
Vital signs (heart rate, blood pressure, respirations and temperature). 
− 
A detailed questionnaire regarding past and current alcohol exposure will be obtained 
(the AUDIT questionnaire will be used, as this is a well validated measurement for 
quantifying alcohol exposure) [appendix 1]. 
− 
Concomitant medication with indication. 
− 
Document current adverse events 
− 
Haematology analysis (haemoglobin, haematocrit, platelet count, white blood cell 
count including differential count) 
− 
Serum chemistry analysis (sodium, potassium, chloride, creatinine, eGFR, 
bicarbonate, total protein, albumin, ALT, AST, ALP, total bilirubin), hsCRP 
− 
Women of childbearing potential: serum pregnancy test 
− 
Hepatitis C antibody test and if positive HCV RNA screening, to be performed if not 
tested within the last 3 months as part of SOC 
− 
Hepatitis B surface antigen test – only to be performed if not tested within the last 3 
months as part of SOC 
− 
CD4+ and CD8+ T-cell count 
− 
Plasma HIV RNA (clinical assay) – only to be performed if not part of standard of care 
tests within the preceding 3 months of anticipated Day 1 of treatment. 
An additional 57.5 mL of blood will be collected for study specific tests which include: 
− 
Plasma HIV RNA (single copy assay) 
− 
CA-US RNA on CD4+ T cells 
− 
Cell associated HIV DNA (total and integrated) in CD4+ cells 
− 
p24 expression 
− 
PBMC and plasma storage 
− 
Plasma storage for measuring disulfiram levels (control) 
− 
Serum storage for measuring vorinostat levels (control) 
8.3 
VISIT 2 - BASELINE 
This baseline visit will occur on the day of initiating study therapy AND prior to the first 
disulfiram dose. 
− 
Eligibility will be reconfirmed 
− 
Medical history ascertained 
− 
Clinical review including vital signs 
− 
Review of current concomitant medications since last visit 
− 
Review of current adverse events since last visit 
− 
6mL blood test for plasma HIV RNA (clinical assay) 
An additional 90.5 mL of blood will be collected for study specific tests which include: 
− 
Plasma HIV RNA (single copy assay) 
− 
CA-US RNA on CD4+ T cells 
− 
Cell associated HIV DNA (total and integrated) in CD4+ cells 
− 
p24 expression 
− 
TILDA assay 
− 
PBMC and plasma storage 


Study Name: Combination Latency Reversing Therapy with Disulfiram plus Vorinostat in HIV Infected Individuals on antiretroviral 
therapy (ART): A Single Arm, Clinical Trial 
Protocol ID: MDS-IIS-55750 
Version & date: 4.0, Dated 17 June 2019 
Page 27 of 46 
− 
Collection of plasma for disulfiram and vorinostat concentrations 
− 
PAX gene tube for storage and future genetic studies 
− 
Plasma storage for measuring disulfiram pK levels (control) 
− 
Serum storage for measuring vorinostat pK level (control) 
8.4 
VISIT 3 – DAY 8 
This visit and procedures will occur prior to both disulfiram AND vorinostat dosing. 
− 
Clinical review including vital signs 
− 
Review of current concomitant medications since last visit 
− 
Review of current adverse events since last visit 
− 
Haematology and serum chemistry analysis 
An additional 60.5 mL of blood will be collected for study specific tests which include: 
− 
Plasma HIV RNA (single copy assay) 
− 
CA-US RNA on CD4+ T cells 
− 
p24 expression 
− 
PBMC and plasma storage 
− 
Collection of plasma for measuring disulfiram pK levels 
− 
Collection of serum for measuring vorinostat pK levels (control in the presence of 
disulfiram) 
− 
PAX gene tube for storage and future genetic studies 
8.5 
VISIT 4 – DAY 11 
This visit and procedures will occur 24 hours after day 10 vorinostat dosing AND before day 
11 disulfiram dosing. 
− 
Vital signs 
− 
Review of current concomitant medications since last visit 
− 
Review of current adverse events since last visit 
− 
Haematology and serum chemistry analysis 
An additional 60.5 mL of blood will be collected for study specific tests which include: 
− 
Plasma HIV RNA (single copy assay) 
− 
CA-US RNA on CD4+ T cells 
− 
p24 expression 
− 
PBMC and plasma storage 
− 
Collection of plasma for measuring disulfiram pK levels 
− 
Collection of serum for measuring vorinostat pK levels 
− 
PAX gene tube for storage and future genetic studies 
8.6 
VISIT 5 – DAY 22 
This visit and procedures will occur prior to both disulfiram AND Vorinostat dosing. 
− 
Clinical review including vital signs 
− 
Review of current concomitant medications since last visit 
− 
Review of current adverse events since last visit 


Study Name: Combination Latency Reversing Therapy with Disulfiram plus Vorinostat in HIV Infected Individuals on antiretroviral 
therapy (ART): A Single Arm, Clinical Trial 
Protocol ID: MDS-IIS-55750 
Version & date: 4.0, Dated 17 June 2019 
Page 28 of 46 
− 
Haematology and serum chemistry analysis   
An additional 57.5 mL of blood will be collected for study specific tests which include: 
− 
Plasma HIV RNA (single copy assay) 
− 
CA-US RNA on CD4+ T cells 
− 
p24 expression 
− 
PBMC and plasma storage 
− 
Collection of plasma for measuring disulfiram pK levels 
− 
Collection of serum for measuring vorinostat pK levels 
8.7 
VISIT 6 – DAY 25 
This visit and procedures will occur 24 hours after day 24 vorinostat dosing AND before day 
25 disulfiram dosing. 
− 
Vital signs 
− 
Review of current concomitant medications since last visit 
− 
Review of current adverse events since last visit 
− 
CD4+ and CD8+ counts 
An additional 60.5 mL of blood will be collected for study specific tests which include: 
− 
Plasma HIV RNA (single copy assay) 
− 
CA-US RNA on CD4+ T cells 
− 
p24 expression 
− 
PBMC and plasma storage 
− 
Collection of plasma for measuring disulfiram pK levels 
− 
Collection of serum for measuring vorinostat pK levels 
− 
PAX gene tube for storage and future genetic studies 
8.8 
VISIT 7 – END OF TREATMENT 
This visit and procedures will occur after the last disulfiram dosing, day 28. 
− 
Clinical review including vital signs 
− 
Review of current concomitant medications since last visit 
− 
Review of current adverse events since last visit 
− 
Haematology analysis (haemoglobin, haematocrit, platelet count, white blood cell 
count including differential count) 
− 
Serum chemistry analysis (sodium, potassium, chloride, creatinine, eGFR, 
bicarbonate, total protein, albumin, ALT, AST, ALP, total bilirubin), hsCRP 
− 
6mL blood test for plasma HIV RNA (clinical assay) 
An additional 57.5 mL of blood will be collected for study specific tests which include: 
− 
Plasma HIV RNA (single copy assay) 
− 
CA-US RNA on CD4+ T cells 
− 
p24 expression 
− 
PBMC and plasma storage 
− 
Collection of plasma for measuring disulfiram pK levels 
− 
Collection of serum for measuring vorinostat pK levels 


Study Name: Combination Latency Reversing Therapy with Disulfiram plus Vorinostat in HIV Infected Individuals on antiretroviral 
therapy (ART): A Single Arm, Clinical Trial 
Protocol ID: MDS-IIS-55750 
Version & date: 4.0, Dated 17 June 2019 
Page 29 of 46 
8.9 
VISIT 8 – SAFETY VISIT 
The visit and procedures will occur on day 56 ± 7 days.  This is 28 days after the last disulfiram 
dose. 
− 
Vital signs 
− 
Review of current concomitant medications since last visit 
− 
Review of current adverse events since last visit 
− 
CD4+ and CD8+ counts 
An additional 87.5 mL of blood will be collected for study specific tests which include: 
− 
Plasma HIV RNA (single copy assay) 
− 
CA-US RNA on CD4+ T cells 
− 
Cell associated HIV DNA (total and integrated) in CD4+ cells 
− 
p24 expression 
− 
TILDA assay 
− 
PBMC and plasma storage 
− 
Collection of plasma for measuring disulfiram pK levels 
− 
Collection of serum for measuring vorinostat pK levels 
8.10 VISIT 9 – END OF STUDY 
The visit and procedures will occur 6 months (168 days) after the last disulfiram dose. 
− 
Vital signs 
− 
Review of current concomitant medications since last visit 
− 
Review of current adverse events since last visit 
− 
Haematology analysis (haemoglobin, haematocrit, platelet count, white blood cell 
count including differential count) 
− 
Serum chemistry analysis (sodium, potassium, chloride, creatinine, eGFR, 
bicarbonate, total protein, albumin, ALT, AST, ALP, total bilirubin), hsCRP 
− 
CD4+ and CD8+ counts 
An additional 70.5 mL of blood will be collected for study specific tests which include: 
− 
Plasma HIV RNA (single copy assay) 
− 
CA-US RNA on CD4+ T cells 
− 
Cell associated HIV DNA (total and integrated) in CD4+ cells 
− 
p24 expression 
− 
PBMC and plasma storage 
− 
Collection of plasma for measuring disulfiram pK levels 
− 
Collection of serum for measuring vorinostat pK levels 
− 
PAX gene tube for storage and future genetic studies 
The total study specific blood volume collected for a participant over the 9 visits (approximately 
6 months) will be 602.5 mL. 


Study Name: Combination Latency Reversing Therapy with Disulfiram plus Vorinostat in HIV Infected Individuals on antiretroviral 
therapy (ART): A Single Arm, Clinical Trial 
Protocol ID: MDS-IIS-55750 
Version & date: 4.0, Dated 17 June 2019 
Page 30 of 46 
9. EFFECT ASSESSMENTS 
9.1 
PLASMA HIV RNA 
HIV RNA in plasma will be measured by the AmpliPrep/COBAS®TaqMan® HIV-1 test 
version 2.0 (Roche Diagnostics) on three occasions and on all other visits, will be measured 
by a real-time PCR assay with single copy sensitivity as previously described2. 
9.2 
TOLERABILITY 
Tolerability will be assessed by systematically recording incidence and severity of adverse 
advents.  For each adverse event we will assess the causal association with study therapy 
(see section 10 for more details) 
9.3 
CELL-ASSOCIATED UNSPLICED HIV RNA 
CA-US HIV RNA will be quantified using a semi-nested real time qPCR with a first round 
amplification of 15 cycles to ensure that the following second round amplification the assay 
was in the linear range between 1 to 46,000 input copies, as previously described by 
Pasternak et al 24.  Primers used for 1st and 2nd round amplified gag 25.  HIV RNA copy 
numbers is standardized to cellular equivalents using an 18s RNA real time LUX PCR primer 
set (Invitrogen).  PCR amplification of cDNA for CA-US RNA is performed in quadruplicate 
with a non-RT control included 
9.4 
P24 EXPRESSION 
Will be measured by using an optimized HIV p24 digital immunoassay on the single-molecule-
array platform using frozen PBMC. 
9.5 
CELL-ASSOCIATED TOTAL AND INTEGRATED HIV DNA 
To measure total and integrated HIV DNA we will perform real time qPCR using primers and 
probes as previously described2.  The qPCR for HIV DNA will be performed in triplicate.  To 
normalise for cell equivalents in the input DNA, a separate real-time qPCR assay will be used 
to quantify the CCR5 gene. 
9.6 
THE FREQUENCY OF INDUCIBLE VIRUS IN CD4+ T CELLS 
We will use the recently developed Tat/rev Induced Limiting Dilution Assay (TILDA) to 
measure the frequency of cells with inducible multiply-spliced (MS) HIV RNA, as these 
transcripts are usually absent in latently infected cells but induced upon viral reactivation26.  
Briefly, CD4+ T cells will be stimulated with phorbol myristate acetate (PMA) and ionomycin 
for 12hrs.  Dilutions of the stimulated cells are then distributed in a 96 well plate and directly 
subjected to quantification of MS HIV RNA by qPCR.  The frequency of positive cells is 
calculated using the maximum likelihood method and expressed as a frequency of cells with 
inducible MS HIV RNA per million CD4+ T-cells. 


Study Name: Combination Latency Reversing Therapy with Disulfiram plus Vorinostat in HIV Infected Individuals on antiretroviral 
therapy (ART): A Single Arm, Clinical Trial 
Protocol ID: MDS-IIS-55750 
Version & date: 4.0, Dated 17 June 2019 
Page 31 of 46 
9.7 
PLASMA LEVELS OF VORINOSTAT AND DISULFIRAM 
Concentrations of vorinostat and disulfiram and its metabolites in plasma will be measured 
using liquid chromatography and mass spectrometry. 
9.8 
NEXT-GENERATION RNA SEQUENCING 
We will perform next-generation RNA sequencing and bioinformatic analyses of gene 
expression activity in samples taken before, during and after study therapy.  This will be done 
by extracting RNA including integrity control, stranded RNA library preparation and using 
Illumina sequencing with 100 bp single reads with enrichment for polyA tail mRNA.  
During the expression analysis samples will undergo quality and adapter trimming, alignment, 
quantification and normalisation to generate output files that will be subject to bioinformatics 
analyses.  
We will use these data to identify differentially expressed genes and affected gene pathways 
before study therapy, during treatment with disulfiram (day 0 – day 8), during treatment with 
disulfiram + vorinostat (day 8 – day 11) and at end of study (months after discontinuation of 
study therapy). 
9.9 
QUNATIFICATION OF PLASMA BIOMARKERS OF NEUROINFLAMMATION AND 
DEGRADATION 
Through a collaboration with Magnus Gisslen and Kaj Blennow at the Clinical Neurochemistry 
Lab, University of Gothenburg, Sweden, we will quantify plasma levels of neurofilament light 
chain (NFL), p-tau and t-tau.  We will assess longitudinal changes in the level of these 
biomarkers and will also compare against biomarker levels in other cohorts of HIV-infected 
individuals. 
9.10 PLASMA CYTOKINES, CHEMOKINES AND GENE PRODUCTS 
We will quantify levels of plasma cytokines and chemokines and selected products of 
differentially expressed genes.  The latter will be based on our bioinformatic analysis of gene 
expression levels as explained in subsection 9.8. This will be done using commercially 
available ELISA kits and Luminex multiplexing to quantify a broad panel of cytokines in 
plasma. 
9.11 HISTONE ACETYLATION AND PTEFB AND NFKB ACTIVATION 
Through a collaboration with Jonathan Karn at Case Western University, USA, we will assess 
markers of cellular function relevant to latency reversal.  We will apply samples from the study 
to several newly developed assays, which includes H3K9 histone acetylation, pTEFB 
activation and NFkB activation. 
9.12 EFFECTS OF VORINOSTAT AND DISULFIRAM ON ASTROCYTES 
To determine the effect of the transcriptome of vorinostat and or disulfiram in cells from the 
central nervous system and peripheral blood mononuclear cells we intend to perform RNA 


Study Name: Combination Latency Reversing Therapy with Disulfiram plus Vorinostat in HIV Infected Individuals on antiretroviral 
therapy (ART): A Single Arm, Clinical Trial 
Protocol ID: MDS-IIS-55750 
Version & date: 4.0, Dated 17 June 2019 
Page 32 of 46 
sequencing on primary astrocytes, astrocyte cell lines and PBMCs.  These different cells will 
be exposed to Cmax drug levels that were observed in the trial.  We will determine H3K9 histone 
acetylation, pTEFB activation and NFkB activation in these cells and determine differential 
gene expression compared to untreated cells.  We will perform bulk RNA sequencing by 
extracting RNA from 2 million treated cells per condition and perform 3’-end poly A paired 
ended 2x100bp sequencing using the Illumina Miseq platform.  We expect that the epigenetic 
markers in these different cell types will react differently to these LRAs. 
10. 
PARTICIPANT SAFETY AND WITHDRAWAL  
10.1 DEFINITIONS 
10.1.1 Adverse Events (AE) 
An AE is any untoward medical occurrence in a patient or clinical investigation participant 
administered a pharmaceutical product that does not necessarily have a causal relationship 
with this treatment.  An AE can therefore be any unfavourable and unintended sign (including 
an abnormal laboratory finding – see below), symptom, or disease temporally associated with 
the use of the investigational drug, whether or not causally linked to the investigational drug. 
An abnormal laboratory value or test result constitutes an adverse event only if 
− 
It is associated with clinical signs or symptoms 
− 
It leads to a change in study drug dosing or discontinuation from the study  
− 
It requires additional diagnostic testing or medical/surgical intervention 
− 
It is considered to be an adverse event by the investigator 
In addition, all cases of drug-drug interaction, pregnancy (with or without outcome), paternal 
exposure, lactation, overdose, drug abuse and misuse, drug maladministration or accidental 
exposure and dispensing errors are collected and data based even if no adverse event has 
been reported.  
All adverse events will be reported in accordance with the principles of Good Clinical Practice 
and the latest requirements of the Medicines for Human Use (Clinical Trials) Regulations. 
10.1.2 Serious Adverse Events (SAEs) 
A SAE is any untoward medical occurrence that at any dose:  
− 
Results in death 
− 
Is life-threatening 
− 
Results in persistent or significant disability/incapacity 
− 
Constitutes a congenital anomaly/birth defect 
− 
Requires inpatient hospitalization or prolongation of existing hospitalization, unless 
hospitalization is for: 
o Routine treatment or monitoring of the studied indication, not associated with 
any deterioration in condition 
o Elective or pre-planned treatment for a pre-existing condition that is unrelated 
to the indication under study and has not worsened since the start of the study 
drug  


Study Name: Combination Latency Reversing Therapy with Disulfiram plus Vorinostat in HIV Infected Individuals on antiretroviral 
therapy (ART): A Single Arm, Clinical Trial 
Protocol ID: MDS-IIS-55750 
Version & date: 4.0, Dated 17 June 2019 
Page 33 of 46 
o Treatment on an emergency outpatient basis for an event not fulfilling any of 
the definitions of a SAE given above and not resulting in hospital admission 
o Social reasons and respite care in the absence of any deterioration in the 
patient's general condition 
− 
Is medically significant, i.e. defined as an event that jeopardizes the patient or may 
require medical or surgical intervention to prevent one of the outcomes listed above 
Unlike routine safety assessments, SAEs are monitored continuously and have special 
reporting. 
10.1.3 Pregnancy 
Any female study participant who becomes pregnant during the study must be immediately 
withdrawn from study drugs to eliminate further exposure to the embryo/foetus.  
Any pregnancy that occurs during study participation is to be reported on a specific pregnancy 
site worksheet and SAE form.  To ensure participant safety, each pregnancy must be reported 
to Sponsor within one week of learning of its occurrence.  The pregnancy must be followed up 
to determine outcome (including premature termination) and status of mother and child, which 
must also be reported to Sponsor using designated data collection forms.  Pregnancy 
complications and elective terminations for medical reasons must be reported as an AE or 
SAE.  Spontaneous abortions must be reported as an SAE. 
Any SAE occurring in association with a pregnancy brought to the investigator’s attention after 
the subject has completed the study and considered by the investigator as possibly related to 
the investigational product, must be promptly reported to Sponsor. 
10.2 RECORDING OF ADVERSE EVENTS 
At each contact with the study participant, as indicated in the schedule of activities, information 
on adverse events is sought by specific questioning and, as appropriate, by examination.  
Information on all adverse events should be recorded immediately in the source document, 
and also in the appropriate adverse event module of the CRF.  All clearly related signs, 
symptoms, and abnormal diagnostic procedures results should be recorded in the source 
document, though they should be grouped under one diagnosis. 
All adverse events occurring during the study period - from the time the study participant signs 
consent (visit 1) to End of study (visit 9) - must be recorded.  The clinical course of each event 
should be followed until resolution, stabilization, or until it has been determined that the study 
treatment or participation is not the cause.  Serious adverse events that are still on-going at 
the End of Study must be followed up to determine the final outcome.  Any serious adverse 
event that occurs after the study period and is considered to be possibly related to the study 
treatment or study participation should be recorded and reported immediately. 
All AEs must be graded according to the Division of AIDS Table for Grading the Severity of 
Adult and Pediatric Adverse Events, Version 2, November 2014 and recorded in source notes 
as well as the AE eCRF with the following information: 
o The severity grade (see below) 
o Its relationship to the study drugs (suspected/not suspected) 
o Its duration (start and end dates or if continuing at study visit) 
o Whether it constitutes a serious adverse event (SAE) 


Study Name: Combination Latency Reversing Therapy with Disulfiram plus Vorinostat in HIV Infected Individuals on antiretroviral 
therapy (ART): A Single Arm, Clinical Trial 
Protocol ID: MDS-IIS-55750 
Version & date: 4.0, Dated 17 June 2019 
Page 34 of 46 
All adverse events will be graded in the following manner: 
o Grade 1 (Mild): Events require minimal or no treatment and do not interfere with the 
participant’s daily activities. 
o Grade 2 (Moderate): Events result in a low level of inconvenience or concern. 
Moderate events may cause some interference with functioning. 
o Grade 3 (Severe): Events interrupt a participant’s usual daily activity and may require 
systemic drug therapy or other treatment. Severe events are usually incapacitating. 
o Grade 4 (Life-threatening): Any adverse drug experience that places the participant, in 
the view of the investigator, at immediate risk of death from the reaction as it occurred 
(i.e., it does not include a reaction that had it occurred in a more severe form, might 
have caused death). 
o Grade 5 (Death) 
10.3 REPORTING OF SERIOUS ADVERSE EVENTS 
SAEs will be noted in source documentation.  Information about all SAEs should be recorded 
on a Serious Adverse Event Report Form.  The investigator must inform the sponsor, principal 
investigator and HREC, assess the relationship to study drug, complete an SAE Report Form, 
and send the signed form by fax within 24 hours of notification of the SAE to Merck Global 
Safety and HREC. 
Merck Global Safety Group: +1 215 993 1220 
The original copy of the SAE Report Form and the fax confirmation sheet or email confirmation 
must be maintained at the study site. 
10.4 SUSPECTED UNEXPECTED SERIOUS ADVERSE REACTIONS (SUSARS) 
If the SAE is not previously documented in the product information or package insert (new 
occurrence) and is thought related to the study drug, it qualifies as a SUSAR.  A sponsor 
associate may require further information from the investigator for Health Authority reporting.   
The minimum necessary information to be provided at the time of the initial report includes: 
• 
An identifiable patient 
• 
An identifiable medicinal and/or pharmaceutical product 
• 
An identifiable reporter 
• 
A serious adverse event 
10.5 REPORTING OF SUSARS TO LOCAL HEALTH AUTHORITY 
The study sponsor is responsible for submission of reportable SUSARs to the local Health 
Authority according to regulatory requirements.  The timeline for reporting any suspected 
adverse reaction that is both serious and unexpected is 15 calendar days after the 
investigator determines that the suspected adverse reaction qualifies for reporting.  
The timeline for reporting any suspected adverse reaction that is both serious and unexpected 
is 7 calendar days for events that are fatal or life threatening.  


Study Name: Combination Latency Reversing Therapy with Disulfiram plus Vorinostat in HIV Infected Individuals on antiretroviral 
therapy (ART): A Single Arm, Clinical Trial 
Protocol ID: MDS-IIS-55750 
Version & date: 4.0, Dated 17 June 2019 
Page 35 of 46 
11. 
STATISTICAL METHODS 
11.1 SAMPLE SIZE ESTIMATION & JUSTIFICATION   
The primary comparison for study is the level of plasma HIV RNA on day 11 during 
disulfiram/vorinostat treatment compared to baseline.  Based on two previous studies of 
LRAs, where treatment with disulfiram 2000 mg or romidepsin led to increases in plasma 
HIV RNA 4,6, we assume a pre-study therapy mean of 1 copy/mL and a standard 
deviation of 11 copies/mL for the increase in plasma HIV RNA.  Based on these numbers, 
the study will require 14 participants to detect an increase in plasma HIV RNA of 10 
copies/mL with 80% power at a 0.05 significance level.  Targeted enrolment is 15 participants 
to accommodate for loss to follow-up. 
No interim analysis is planned. 
11.2 ANALYSES OF PRIMARY AND SECONDARY ENDPOINTS 
The primary comparisons will be made using paired t-test or signed-rank test as 
appropriate.  By applying the same statistical methods, we will also analyse whether 
changes in CA-US HIV RNA and plasma HIV RNA differ following administration of high 
dose disulfiram and vorinostat.  We will use repeated measurement analysis of variance 
statistics and/or generalized estimating equation statistics to analyse overall changes in 
primary and secondary endpoints during study intervention by including all data points during 
study therapy.  P-values <0.05 will be considered significant. 
The tolerability population will include all participants who have received at least one dose of 
vorinostat or disulfiram.  Adverse events (AEs) and serious adverse events (SAEs) will be 
summarized according to severity assessment showing the number and percentage of 
participants experiencing at least one event, the number of events, and the causality 
assessment.  No formal statistical comparisons will be made – AE rates are presented for 
descriptive purposes.  
11.3 GENE EXPRESSION DATA AND ADDITIONAL ANALYSES TO INVESTIGATE 
NEUROTOXICITY (SECTIONS 9.8 – 9.12) 
RNA sequencing data will undergo standard bioinformatic analyses, which is performed by 
Australian Genome Research Facility (AGRF), Melbourne.  This will include quality and 
adapter trimming, alignment, quantification and normalisation. RNA expression data will be 
mapped to a reference genome and gene expression levels will be compared across different 
time points to identify differentially expressed genes.  Differential expression of gene pathways 
will be analysed using Kyoto Encyclopedia of Genes and Genomes (KEGG) and Reactome 
platforms.  
Other additional analyses related to observed neurotoxicity include plasma levels of cytokines, 
biomarkers of neuronal injury, levels of histone acetylation, pTEFB and NFkB activation and 
effects of disulfiram with or without vorinostat on primary astrocytes, astrocyte cell lines and 
PBMCs.  These data will be summarised using descriptive statistics.  Where feasible different 
time points or conditions will be compared using paired t-test or signed-rank test.  


Study Name: Combination Latency Reversing Therapy with Disulfiram plus Vorinostat in HIV Infected Individuals on antiretroviral 
therapy (ART): A Single Arm, Clinical Trial 
Protocol ID: MDS-IIS-55750 
Version & date: 4.0, Dated 17 June 2019 
Page 36 of 46 
12. 
STORAGE OF BLOOD SAMPLES 
Blood samples will be collected for PBMC and plasma storage at each visit as indicated in 
section 8 of this protocol.  Samples will be stored at the Doherty Institute, University of 
Melbourne (Lewin Laboratory) and will only be accessible to research staff following approval 
by the Protocol Steering Committee, which will include Professor Sharon Lewin, Dr James 
McMahon, Dr Tina Schmidt and a community representative.  Stored samples may be used 
for future analyses conditioned on adherence to local regulations and ethical guidelines and 
approval of human research ethics committee. 
13. 
ETHICAL CONSIDERATIONS 
13.1 STUDY APPROVAL 
Sponsor must obtain prospective approval before study initiation of the study protocol, 
informed consent documents and other relevant documents from the HREC and the 
Therapeutic Goods Administration (TGA) through the Clinical Trial Notification (CTN) scheme.  
13.2 ETHICAL CONDUCT OF THE STUDY 
The Sponsor and principal investigator is responsible for planning and conducting the study 
in accordance with The Helsinki Declaration (1996 version), guidelines for Good Clinical 
Practice (GCP; International Conference on Harmonization 1996), and Australian ethical 
guidelines and law. 
13.3 HREC REVIEW AND INFORMED CONSENT 
This protocol, the informed consent document and any subsequent modifications will be 
reviewed and approved by the HREC responsible for oversight of the study.  A signed consent 
form will be obtained from each study participant prior to any study procedures.  The consent 
form will describe the purpose of the study, the procedures to be followed, and the potential 
risks and benefits of participation.  A copy of the consent form will be given to the study 
participant, parent, or legal guardian.  During the informed consent process, research staff will 
ensure that potential participants understand the purpose of the study, the study intervention, 
study procedures, any risks associated with participation and that participation is voluntary.  
Any questions posed during the informed consent process or subsequently during the study 
will be carefully addressed.  Potential participants will be given as much time as they need to 
read and understand the consent form.   
13.4 HARMS, RISKS AND INCONVENIENCES 
The potential harms, risks and/or inconveniences associated with participation in this study 
will be that of exposure to the study drugs disulfiram and vorinostat, the risk of phlebotomy, 
the risk of pregnancy in women of childbearing potential and the inconveniences associated 
with attending study visits.  To monitor the safety and ensure the well-being of study 
participants, monitoring and handling of adverse events will be done at study visits as detailed 
in section 8 and 10 of this protocol.  In the event of adverse effects, participants will have 


Study Name: Combination Latency Reversing Therapy with Disulfiram plus Vorinostat in HIV Infected Individuals on antiretroviral 
therapy (ART): A Single Arm, Clinical Trial 
Protocol ID: MDS-IIS-55750 
Version & date: 4.0, Dated 17 June 2019 
Page 37 of 46 
medical care available through the Alfred Hospital.  Any medical testing and evaluation 
undertaken by study investigators to follow up abnormal findings will also be at no cost to 
participants. 
13.4.1 Disulfiram 
Undesirable effects of disulfiram are reported in individuals that have not abstained from 
alcohol, which results in a disulfiram-ethanol toxic reaction, as specified in the product 
information and includes an intense cutaneous flushing from the head downwards, involving 
the face, sclera, upper limbs, and chest.  The cutaneous flushing is caused by vasodilation 
and is accompanied by a sensation of heat and sweating, palpitations, with tachycardia, 
dyspnoea, hyperventilation and the patient develops a pounding headache.  There is a feeling 
of constriction and irritation of the throat and trachea, resulting in spasms of coughing.  Chest 
pains may occur simulating coronary spasm.  Restlessness or a sense of uneasiness and fear 
of dying may develop.  These symptoms are accompanied by a steep rise in blood pressure, 
followed by hypotension if vasodilation is significant.  Flushing is then replaced by pallor, 
weakness, vertigo, and nausea develops that turns into violent vomiting with abdominal 
cramps.  Other symptoms reported include thirst, dizziness, blurred vision, numbness of hands 
and feet, and insomnia.  Severe reactions may affect the heart, and there may be convulsions, 
loss of consciousness, and death from cardio-respiratory failure.   
The intensity of the reaction varies with the individual and the duration of the reaction 
continues as long as there is ethanol in the blood.  Confusion, drowsiness and sleep usually 
follow. Frequently, there are transient ECG changes, such as flattening of T waves, depression 
of S-T segment, and Q-T prolongation in a pattern suggestive of right ventricular strain. 
13.4.2 Vorinostat 
The most common drug-related adverse reactions, which have been reported in cancer 
patients can be classified into 4 symptom complexes. 
1. Gastrointestinal symptoms. Anorexia, nausea, vomiting, diarrhoea, weight loss and 
constipation have been reported.  Antiemetic and antidiarrheal medications have been 
used with good effect.  Fluid and electrolyte replacement may be required. Patients 
should be encouraged to drink at least 2L of fluid each day, and aggressive 
management of nausea and diarrhoea is strongly encouraged, to avoid renal 
impairment secondary to dehydration.  
2. Constitutional symptoms. Fatigue has been reported commonly with use of vorinostat 
and occurred more commonly at doses of vorinostat greater than 400mg per day.  
Chills and fever have also been reported. 
3. Hematologic abnormalities. Dose-related anaemia and thrombocytopenia can occur 
with vorinostat and are more common at doses of more than 400mg per day. 
Neutropenia is uncommon, but has been reported.  Monitoring of blood cell counts 
should be performed every 2 weeks during the first 2 months of therapy and monthly 
thereafter.  If platelet counts and/or haemoglobin are reduced during treatment with 
vorinostat, the dose should be modified or therapy discontinued. 
4. Taste disorders. Dysgeusia and dry mouth have been reported with use of vorinostat.  
The most common serious adverse events, regardless of causality, in the 86 CTCL patients 
in two clinical studies were pulmonary embolism reported in 4.7% (4/86) of patients, squamous 


Study Name: Combination Latency Reversing Therapy with Disulfiram plus Vorinostat in HIV Infected Individuals on antiretroviral 
therapy (ART): A Single Arm, Clinical Trial 
Protocol ID: MDS-IIS-55750 
Version & date: 4.0, Dated 17 June 2019 
Page 38 of 46 
cell carcinoma reported in 3.5% (3/86) of patients and anaemia reported in 2.3% (2/86) of 
patients.  Patients on vorinostat should therefore be monitored for pertinent signs or symptoms 
of deep vein thrombosis or pulmonary embolism.  
Of the CTCL patients who received the 400-mg once daily dose, 9.3% (8/86) of patients 
discontinued vorinostat due to adverse events and 10.5% (9/86) of patients required a dose 
modification due to adverse events.  The median time to the first adverse event resulting in 
dose reduction was 42 days (range 17 to 263 days). 
Laboratory abnormalities were reported in the 86 patients who received the 400-mg dose and 
one patient who received a 350-mg dose. 
Increased serum glucose was detected by laboratory safety tests in 69% (60/87) of CTCL 
patients, but was severe (Grade 3) in only 5 of these.  Hyperglycaemia was reported as a 
drug-related adverse experience in 4.7% (4/86) of CTCL patients who received the 400–mg 
once daily dose.  Serum glucose should be monitored, especially in diabetic or potentially 
diabetic patients.  Adjustment of diet and/or therapy for increased glucose may be necessary. 
Blood glucose monitoring of diabetic patients is recommended. 
Transient increases in serum creatinine were detected in 47.1% (41/87) of CTCL patients; in 
most cases these increases were non-severe, however, Grade III (severe) cases have been 
observed.  Based on reports of dehydration as a serious drug-related adverse experience in 
clinical trials, patients were instructed to drink at least 2 L/day of fluids for adequate hydration.  
After these precautions were implemented, the incidence of dehydration decreased. 
Proteinuria was detected as a laboratory abnormality (51.4%) in 38 of 74 patients tested.  The 
clinical significance of this finding is unknown. 
A phase 1 study has been performed of 25 patients given a single supratherapeutic dose of 
vorinostat 800mg.  Of the 24 patients included in analysis, no patient had a significant change 
in QTc over 24 hours of monitoring.  In other studies three of 86 CTCL patients exposed to 
400mg once daily had Grade 1-2 QTc prolongation.  In a retrospective analysis of three Phase 
I trials and two Phase II trials, 4 of 116 evaluable patients had grade 2 QTc prolongation, and 
1/116 had grade 3 QTc prolongation.  Of 49 non-CTCL patients from 3 clinical trials 1 had 
grade 2 prolongation and 2 had grade 3 QTc prolongation.  Baseline and periodic ECGs 
should be performed during treatment.  Vorinostat should be administered with particular 
caution in patients with congenital long QT syndrome, and patients taking anti-arrhythmic 
medicines or other medicinal products that lead to QT prolongation.  Hypokalemia or 
hypomagnesemia should be corrected prior to administration of vorinostat, and consideration 
should be given to monitoring potassium and magnesium in symptomatic patients (e.g., 
patients with nausea, vomiting, diarrhoea, fluid imbalance or cardiac symptoms). 
13.4.3 Reproductive risks 
Safe use of either disulfiram or vorinostat in human pregnancy or during lactation has not been 
established. 
Available reproductive toxicity studies in animals do not necessitate that females of 
childbearing potential are excluded from clinical trials of disulfiram or vorinostat, but use of 
effective contraception for both males and females are required for participation in this study.  
In addition, for female participants, a negative pregnancy tests is required during screening. 


Study Name: Combination Latency Reversing Therapy with Disulfiram plus Vorinostat in HIV Infected Individuals on antiretroviral 
therapy (ART): A Single Arm, Clinical Trial 
Protocol ID: MDS-IIS-55750 
Version & date: 4.0, Dated 17 June 2019 
Page 39 of 46 
13.4.4 Phlebotomy 
Phlebotomy may cause some discomfort, bleeding or bruising where the needle enters the 
skin, and rarely, fainting or infection may occur.  
13.5 RISK/BENEFIT ANALYSIS 
Even though the implementation of combination ART to treat HIV infection has had a 
tremendous impact on the epidemic by restoring the health of well-treated individuals, HIV 
infection remains a major public health challenge world-wide.  Moreover, as ART 
discontinuation invariably results in viral rebound to pre-treatment levels, the development of 
a cure for HIV continues to be a fundamental goal in infectious disease research.  Although 
the initial studies of LRAs showed no decline in latently infected cells, it is likely that an 
effective intervention to reverse latency will be needed in combination with interventions that 
eliminate latently infected cells. Identification of safe interventions that can increase potency 
of latency reversal remains a high scientific priority. 
The design of the study with a relatively short administration of the well-studied and safe drug 
disulfiram, together with a short period of administration of vorinostat to background ART is 
aimed at increasing the potency of latency reversal.  As such, it is unlikely that participation is 
associated with any sustained significant clinical benefit for the participants.  Hence, any 
benefits accrued by completing this study will primarily be for society rather than the individual 
study participant. 
The harms, risks and inconveniences associated with study participation are outlined above 
and include known and unknown adverse effects of both disulfiram and vorinostat, 
reproductive risks and phlebotomy.  These risks have been minimized by choosing a relatively 
short period for the study intervention, by excluding candidates with any condition that would 
increase the risk of adverse effects and by the proper conduct and monitoring of the study.  
Given these considerations, we believe that this study is ethically and scientifically justified.  
14. 
STUDY MONITORING AND QUALITY ASSURANCE 
14.1 THE RESPONSIBILITIES OF SPONSOR AND PRINCIPAL INVESTIGATOR 
The sponsor is responsible for establishing and maintaining a quality assurance system that 
guarantees the quality of the study in all aspects.  The principal investigator can appoint 
qualified staff co-investigators that may assist in the conduct of the study in accordance with 
the study protocol.  All co-investigators must be appointed and recorded on the study 
personnel list in due time before any study related procedures are carried out and must be 
supplied with the study protocol and all necessary information.  Co-investigators are 
supervised by the principal investigator and act under her responsibility.  
The sponsor must notify the regulatory authorities and the HREC about the completion of the 
study in accordance with local regulation.  If the study is prematurely terminated this must be 
notified and the reason for this must be clarified. 


Study Name: Combination Latency Reversing Therapy with Disulfiram plus Vorinostat in HIV Infected Individuals on antiretroviral 
therapy (ART): A Single Arm, Clinical Trial 
Protocol ID: MDS-IIS-55750 
Version & date: 4.0, Dated 17 June 2019 
Page 40 of 46 
14.2 STUDY MONITORING/AUDIT 
The study will be monitored by an internal staff member of the Department of Infectious 
Diseases, Alfred Hospital and/or Melbourne University, as per department protocol.  The study 
monitor will visit the clinical research site to monitor and assess the conduct of the study.  
Adherence to protocol and regulatory requirements will be monitored as well as the handling 
of irregularities if such occur.  Study monitoring also includes review of drug storage and 
management.  During monitoring visits all, but not necessarily limited to, of the following issues 
will be discussed and assessed: informed consent, participant recruitment, follow-up, 
documentation, recording and reporting of AE and SAE, compliance, data quality, and data 
handling.  The study 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 study monitor and/or HREC if required. 
15. 
DATA HANDLING & RECORD KEEPING 
15.1 HANDLING OF PERSONAL INFORMATION 
Study investigators and associated research staff must handle and keep all study material and 
documents as confidential information and take steps to prevent wrongful or premature 
destruction of these.  All personal data are protected in accordance with relevant Australian 
law.  Blood samples and person-specific documents will not contain information that directly 
identifies the study participant, but will be supplied with a study ID unique for each participant.  
To enable evaluations and/or audits from regulatory authorities or HREC, the principal 
investigator will keep study records including the identity of all study participants, e.g. CRFs, 
signed informed consent documents, AE/SAE forms, source documents and study 
correspondence.  As this is a CTN drug trial, records will be maintained by the principal 
investigator according local regulation which is a minimum of 15 years post study closure. 
15.2 DATA MANAGEMENT 
All clinical data for this study will be managed by the Data Management Unit at the clinical 
research unit for the Department of Infectious Diseases at Alfred Health.  The study database 
will be managed by the sponsor. 
All trial data required for the monitoring and analysis of the study will be recorded on the 
eCRFs provided.  All required data entry fields must be completed.  Data corrections will be 
done according to the instructions provided.  The investigator will be asked to confirm the 
accuracy of completed CRFs by signing key CRFs as indicated. 
15.3 STORAGE OF BIOLOGICAL MATERIAL AND GENETIC TESTING 
Blood samples will be collected for PBMC and plasma storage at each visit as indicated in 
section 8 of this protocol.  Stored samples may be used for future analyses related to HIV cure 
research, including genetic testing, conditioned on adherence to local regulations and ethical 
guidelines.  Samples will be stored at the Doherty Institute, University of Melbourne (Lewin 


Study Name: Combination Latency Reversing Therapy with Disulfiram plus Vorinostat in HIV Infected Individuals on antiretroviral 
therapy (ART): A Single Arm, Clinical Trial 
Protocol ID: MDS-IIS-55750 
Version & date: 4.0, Dated 17 June 2019 
Page 41 of 46 
Laboratory) and will only be accessible to research staff following approval by the Protocol 
Committee. 
16. 
FINANCES 
The total cost of the study is estimated at approximately $200,000 AUD, and will be provided 
by a Merck Investigator Initiated Study grant to the sponsor.  Merck will also supply vorinostat 
for use in this study. 
Study participants will be offered reimbursement for costs attending study visits. 
17. 
PUBLICATION OF THE STUDY 
17.1 PUBLIC REGISTRATION OF STUDY 
The study will be registered at www.clinicaltrials.gov prior to study start; a brief outline of the 
study will be available according to current guidelines. 
17.2 PUBLICATION OF THE STUDY 
Research findings from this study will be published in a timely manner in international peer-
reviewed journals.  The principal investigator, in collaboration with the protocol steering 
committee will have overall responsibility for the content of such publications. 
 
 


Study Name: Combination Latency Reversing Therapy with Disulfiram plus Vorinostat in HIV Infected Individuals on antiretroviral 
therapy (ART): A Single Arm, Clinical Trial 
Protocol ID: MDS-IIS-55750 
Version & date: 4.0, Dated 17 June 2019 
Page 42 of 46 
18. 
REFERENCES 
1. 
Deeks, S. G. HIV: Shock and kill. Nature 487, 439-440, doi:10.1038/487439a (2012).  
2. 
Elliott, J. H. et al. Activation of HIV Transcription with Short-Course Vorinostat in HIV-
Infected Patients on Suppressive Antiretroviral Therapy. PLoS pathogens 10, e1004473, 
doi:10.1371/journal.ppat.1004473 (2014).  
3. 
Rasmussen, T. A. et al. Panobinostat, a histone deacetylase inhibitor, for latent-virus 
reactivation in HIV-infected patients on suppressive antiretroviral therapy: a phase 1/2, 
single group, clinical trial. Lancet HIV 1, e13-21, doi:10.1016/S2352-3018(14)70014-1 
(2014).  
4. 
Sogaard, O. S. et al. The Depsipeptide Romidepsin Reverses HIV-1 Latency In Vivo. 
PLoS pathogens 11, e1005142, doi:10.1371/journal.ppat.1005142 (2015).  
5. 
Spivak, A. M. et al. A pilot study assessing the safety and latency-reversing activity of 
disulfiram in HIV-1-infected adults on antiretroviral therapy. Clin Infect Dis 58, 883-890, 
doi:10.1093/cid/cit813 (2014).  
6 
Elliott, J. H. et al. Short-term administration of disulfiram for reversal of latent HIV infection: 
a phase 2 dose-escalation study. Lancet HIV 2, e520-529, doi:10.1016/S2352-
3018(15)00226-X (2015).  
7 
Bullen, C. K., Laird, G. M., Durand, C. M., Siliciano, J. D. & Siliciano, R. F. New ex vivo 
approaches distinguish effective and ineffective single agents for reversing HIV-1 latency 
in vivo. Nat Med 20, 425-429, doi:10.1038/nm.3489 (2014).  
8 
Kumar, A., Darcis, G., Van Lint, C. & Herbein, G. Epigenetic control of HIV-1 post 
integration latency: implications for therapy. Clin Epigenetics 7, 103, doi:10.1186/s13148-
015-0137-6 (2015).  
9 
Budhiraja, S., Famiglietti, M., Bosque, A., Planelles, V. & Rice, A. P. Cyclin T1 and CDK9 
T-loop phosphorylation are downregulated during establishment of HIV-1 latency in 
primary resting memory CD4+ T cells. J Virol 87, 1211-1220, doi:10.1128/JVI.02413-12 
(2013).  
10. Mota, T. M. et al. in International Aids Society (IAS) Towards an HIV Cure Symposium 
2015 (Vancouver, Canada, 2015).  
11 Laird, G. M. et al. Ex vivo analysis identifies effective HIV-1 latency-reversing drug 
combinations. The Journal of clinical investigation 125, 1901-1912, doi:10.1172/JCI80142 
(2015).  
12 Van Lint, C., Emiliani, S., Ott, M. & Verdin, E. Transcriptional activation and chromatin 
remodeling of the HIV-1 promoter in response to histone acetylation. Embo J 15, 1112-
1120 (1996).  
13 Bartholomeeusen, K., Fujinaga, K., Xiang, Y. & Peterlin, B. M. Histone deacetylase 
inhibitors (HDACis) that release the positive transcription elongation factor b (P-TEFb) 
from its inhibitory complex also activate HIV transcription. J Biol Chem 288, 14400-14407, 
doi:10.1074/jbc.M113.464834 (2013).  
14. Xing, S. et al. Disulfiram reactivates latent HIV-1 in a Bcl-2-transduced primary CD4+ T 
cell model without inducing global T cell activation. J Virol 85, 6060-6064, 
doi:10.1128/JVI.02033-10 (2011).  
15. Archin, N. M. et al. Expression of latent HIV induced by the potent HDAC inhibitor 
suberoylanilide hydroxamic acid. AIDS Res.Hum.Retroviruses 25, 207-212 (2009).  


Study Name: Combination Latency Reversing Therapy with Disulfiram plus Vorinostat in HIV Infected Individuals on antiretroviral 
therapy (ART): A Single Arm, Clinical Trial 
Protocol ID: MDS-IIS-55750 
Version & date: 4.0, Dated 17 June 2019 
Page 43 of 46 
16 Wightman, F., Ellenberg, P., Churchill, M. & Lewin, S. R. HDAC inhibitors in HIV. Immunol 
Cell Biol 90, 47-54, doi:10.1038/icb.2011.95 (2012).  
17. Archin, N. M. et al. Administration of vorinostat disrupts HIV-1 latency in patients on 
antiretroviral therapy. Nature 487, 482-485, doi:10.1038/nature11286 (2012).  
18. Falkenberg, K. J. & Johnstone, R. W. Histone deacetylases and their inhibitors in cancer, 
neurological diseases and immune disorders. Nat Rev Drug Discov 13, 673-691, 
doi:10.1038/nrd4360 (2014).  
19. Jones, R. B. et al. Histone Deacetylase Inhibitors Impair the Elimination of HIV-Infected 
Cells 
by 
Cytotoxic 
T-Lymphocytes. 
PLoS 
pathogens 
10, 
e1004287, 
doi:10.1371/journal.ppat.1004287 (2014).  
20. Fuller, R. K. & Gordis, E. Does disulfiram have a role in alcoholism treatment today? 
Addiction 99, 21-24 (2004).  
21. Talbott, G. D. & Gander, O. Antabuse, 1973. Md State Med J 22, 60-63 (1973).  
22. Archin, N. M. et al. HIV-1 expression within resting CD4+ T cells after multiple doses of 
vorinostat. J Infect Dis 210, 728-735, doi:10.1093/infdis/jiu155 (2014).  
23. Palmer, S. et al. New real-time reverse transcriptase-initiated PCR assay with single-copy 
sensitivity for human immunodeficiency virus type 1 RNA in plasma. J.Clin.Microbiol. 41, 
4531-4536 (2003).  
24. Pasternak, A. O. et al. Cellular levels of HIV unspliced RNA from patients on combination 
antiretroviral therapy with undetectable plasma viremia predict the therapy outcome. 
PLoS One 4, e8490, doi:10.1371/journal.pone.0008490 (2009).  
25. Lewin, S. R. et al. Use of real-time PCR and molecular beacons to detect virus replication 
in human immunodeficiency virus type 1-infected individuals on prolonged effective 
antiretroviral therapy. J Virol 73, 6099-6103 (1999).  
26. Procopio, F. A. et al. A Novel Assay to Measure the Magnitude of the Inducible Viral 
Reservoir 
in 
HIV-infected 
Individuals. 
EBioMedicine 
2, 
872-881, 
doi:10.1016/j.ebiom.2015.06.019 (2015). 
27. Vandergeeten C, et al. Cross-Clade Ultrasensitive PCR-Based Assays To Measure HIV 
Persistence in Large-Cohort Studies. J Virol 88(21):12385-12396 (2014). 
28. Palmer S, et al. Low-level viremia persists for at least 7 years in patients on suppressive 
antiretroviral therapy. Proc.Natl.Acad.Sci.U.S.A 105(10):3879-3884 (2008). 
29. Bouchat S, et al. Sequential treatment with 5-aza-2’-deoxycytidine and deacetylase 
inhibitors reactivates HIV-1. EMBO Mol Med 8:117-138 (2016) 
30. Bouchat S, et al. Histone methyltranserase inhibitors induce HIV-1 recovery in resting 
CD4+ T cells from HIV-1 infected HAART-treated patients. AIDS 26(12):1473-1482 
(2012). 
31. Tripathy MK, et al. H3K27 Demethylation at the proviral promoter sensitizes latent HIV to 
the effects of Vorinostat in Ex vivo cultures of resting CD4+ T cells. J Virol 89(16):8392-
8405 (2105) 
 
 


Study Name: Combination Latency Reversing Therapy with Disulfiram plus Vorinostat in HIV Infected Individuals on antiretroviral 
therapy (ART): A Single Arm, Clinical Trial 
Protocol ID: MDS-IIS-55750 
Version & date: 4.0, Dated 17 June 2019 
Page 44 of 46 
APPENDIX 1 – AUDIT QUESTIONNAIRE 
This questionnaire contains some questions about your use of alcoholic beverages during the 
past year. 
As part of the screening process for this research project, it is important that we know this 
information.  The information will assist in giving you an idea whether participation in this study 
is feasible.  By participating in this study, your body will not be able to breakdown alcohol 
normally, as the study drug Disulfiram interferes with the process.  
Therefore, we ask you to complete this questionnaire that asks about your use of alcoholic 
beverages during the past year.  Please answer as accurately and honestly as possible. 
Field Title 
Field Type 
Field options/instructions 
Date of questionnaire 
Date (DD/MM/YYYY) and time 
(HH:MM) 24 hr format 
Automatically 
date 
and 
time 
stamped by REDCap database 
1. How often do you have a 
drink containing alcohol? 
- 
Never 
- 
Monthly or less 
- 
2 - 4 times a month 
- 
3 - 4 times a week 
- 
4 or more times a week 
Dropdown field – only 1 option can 
be selected 
If Never is chosen, then participants
skip to question 9 
2. How many drinks containing 
alcohol do you have on a 
typical day when you are 
drinking? 
- 
1 or 2 
- 
3 or 4 
- 
5 or 6 
- 
7, 8 or 0 
- 
10 or more 
Dropdown field – only 1 option 
can be selected 
3. How often do you have six or 
more drinks on one occasion? 
- 
Never 
- 
Monthly or less 
- 
2 - 4 times a month 
- 
3 – 4 times a week 
- 
4 or more times a week 
Dropdown field – only 1 option 
can be selected 
4. How often during the last year 
have you found that you were 
not able to stop drinking once 
you had started? 
- 
Never 
- 
Monthly or less 
- 
2 - 4 times a month 
- 
3 - 4 times a week 
- 
4 or more times a week 
Dropdown field – only 1 option can 
be selected 
5. How often during the last year 
have you failed to do what is 
normally expected from you 
because of drinking? 
- 
Never 
- 
Monthly or less 
- 
2 - 4 times a month 
- 
3 – 4 times a week 
- 
4 or more times a week 
Dropdown field – only 1 option 
can be selected 
6. How often during the last year  
have you been unable to 
remember what happened the 
night before because you had 
been drinking? 
- 
Never 
- 
Monthly or less 
- 
2 to 4 times a month 
- 
2 to 3 times a week 
- 
4 or more times a week 
Dropdown field – only 1 option 
can be selected 


Study Name: Combination Latency Reversing Therapy with Disulfiram plus Vorinostat in HIV Infected Individuals on antiretroviral 
therapy (ART): A Single Arm, Clinical Trial 
Protocol ID: MDS-IIS-55750 
Version & date: 4.0, Dated 17 June 2019 
Page 45 of 46 
7. How often during the last year 
have you needed an alcoholic 
drink first thing in the morning to 
get yourself going after a night of 
heavy drinking? 
- 
Never 
- 
Monthly or less 
- 
2 to 4 times a month 
- 
2 to 3 times a week 
- 
4 or more times per week 
Dropdown field – only 1 option 
can be selected 
8. How often during the last year 
have you had a feeling of guilt or 
remorse after drinking? 
- 
Never 
- 
Monthly or less 
- 
2 to 4 times a month 
- 
2 to 3 times a week 
- 
4 or more times per week 
Dropdown field – only 1 option 
can be selected 
9. Have you or someone else 
been injured as a result of you 
drinking? 
- 
Yes 
- 
No 
Dropdown field – only 1 option 
can be selected 
10. Has a relative, friend, or 
another health professional 
expressed concern about your 
drinking or suggested you cut 
down? 
- 
Yes 
- 
No 
Dropdown field – only 1 option 
can be selected 
11. Participation in this research 
study will require you not to 
drink alcohol from 1 day before 
commencing study treatment to 
2 weeks after your last study 
drug – a total of approximately 
6.5 weeks. 
 
Are you happy not to drink any 
alcohol during this period? 
- 
Yes 
- 
No 
Dropdown field – only 1 option 
can be selected