Conditions: Hepatitis B
Allocation: RANDOMIZED | Intervention model: PARALLEL
Enrollment: 201
Healthy volunteers: no

Brief summary:
This clinical trial compares the efficacy of peginterferon plus tenofovir for 24 weeks followed by monotherapy with tenofovir for a further 3.5 years to the efficacy of tenofovir alone given for 4 years in patients with chronic hepatitis B. The primary measure of outcome will be HBsAg loss in serum at 48 weeks after stopping all antiviral therapy (sustained off-treatment response).

Detailed description:
The objective of this study is to compare the long-term efficacy of treatment with combination therapy with peginterferon plus tenofovir versus tenofovir monotherapy in the treatment of chronic hepatitis B.

This is a randomized (1:1) parallel group design trial comparing (i) tenofovir disoproxil fumarate (TDF) 300 mg daily for 192 weeks (4 years) and (ii) peginterferon alfa-2a 180 µg weekly for 24 weeks plus Tenofovir DF 300 mg daily for 192 weeks (4 years). Enrolled participants will be stratified by HBeAg status (positive/negative), genotype (A vs. all others) and cirrhosis (present vs. absent). After 192 weeks of treatment, participants meeting criteria for treatment discontinuation will stop treatment and be followed for 48 weeks (total duration of treatment and follow up is 240 weeks). Emtricitabine/tenofovir coformulated as Truvada, approved for treatment of HIV but not for treatment of hepatitis B virus (HBV) infection, will be offered to patients with primary nonresponse, partial virological response or confirmed virologic breakthrough.

Arms:
arm 1: Tenofovir 192 weeks arm 2: A combination of peginterferon-alfa 2a plus tenofovir for 24 weeks and then tenofovir only for 168 weeks

Interventions: intervention 1: Tenofovir intervention 2: Peginterferon-alfa 2a and tenofovir
Intervention descriptions: intervention 1: 300 mg daily for 192 weeks (4 years) intervention 2: A combination of peginterferon-alfa 2a 180 µg weekly plus tenofovir 300 mg daily for 24 weeks and then only tenofovir 300 mg daily for 168 weeks (3.5 years).

Protocol document:
Prot_SAP_000.pdf: 
Official Study Title: Combination Therapy of Peginterferon Alfa-2a and Tenofovir versus 
Tenofovir Monotherapy in HBeAg-positive and HBeAg-negative Chronic Hepatitis B 
Study Protocol and Statistical Analysis Plan Version 7.0 
10/23/2018 
NCT01369212 


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Combination Therapy of Peginterferon Alfa-2a and Tenofovir versus Tenofovir 
Monotherapy in HBeAg-positive and HBeAg-negative Chronic Hepatitis B  
 
Hepatitis B Research Network 
 
Synopsis 
 
Study Aims 
To define the role of limited duration peginterferon-alfa 2a in the presence of tenofovir in 
treating patients with chronic hepatitis B by: 
 
• 
Comparing the long-term efficacy of initial treatment with combination therapy 
consisting of peginterferon alfa-2a plus tenofovir DF versus tenofovir DF 
monotherapy  
• 
Evaluating “off treatment” sustained responses following combination therapy 
with peginterferon alfa-2a plus tenofovir DF versus tenofovir DF monotherapy  
 
Type of Study 
• 
Randomized treatment trial 
 
Clinical Trial 
This is a randomized (1:1) parallel group design trial comparing (i) tenofovir DF 300 mg 
daily for 192 weeks (4 years) and (ii) peginterferon alfa-2a 180 µg weekly for 24 weeks 
plus tenofovir DF 300 mg daily for 192 weeks (4 years).  Enrolled participants will be 
stratified by HBeAg status (positive/negative), known genotype (A  vs. all others) and 
cirrhosis (present vs. absent).  After 192 weeks of treatment, participants meeting criteria 
for treatment discontinuation will stop treatment and be followed for up to 48 weeks (total 
duration of treatment and follow up is up to 240 weeks). Emtricitabine/tenofovir 
coformulated as Truvada, approved for treating HIV but not for treating HBV infection, 
will be offered to participants with primary nonresponse, partial virological response or 
confirmed virologic breakthrough.  
 
1. Background  
Chronic infection with the hepatitis B virus (HBV) is prevalent world-wide (estimated to 
affect 360 million individuals) and in the United States (estimated to affect 2 million 
individuals) (1).  Chronic hepatitis B may result in progressive liver disease that leads to 
cirrhosis, end-stage liver disease and hepatocellular carcinoma (HCC).  Chronic 
hepatitis B can also be benign and non-progressive, evolving into an inactive carrier 
state that rarely leads to significant liver injury or HCC.  Over the last few years, several 
highly effective antiviral agents have been developed and approved for use in the 
treatment of chronic hepatitis B (2).  Nevertheless, uncertainty remains about which 
patients warrant therapy with which agent or agents, for how long, and with what 
ultimate endpoint as a measure of clinical benefit.   
 
Indications and approaches to therapy of hepatitis B are based upon knowledge of the 
features of its natural history.  The natural history of chronic hepatitis B, particularly if 
acquired in early childhood, runs through several stages or phases that have different 
clinical manifestations and implications for long-term hepatic injury (3, 4).  Typically, 
there is an early inactive “immune tolerant” phase marked by the presence of high levels 
of HBsAg, HBeAg and HBV DNA, but minimal or no elevations in serum alanine and 


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aspartate aminotransferase levels (ALT, AST) and minimal activity or injury on liver 
biopsy (5).  The immune tolerant phase is variable in duration, but is typically followed in 
adolescence or early adulthood by an active “immune clearance” phase, marked by rises 
in serum ALT and AST, inflammation and hepatocellular necrosis on liver biopsy and 
somewhat lower levels of serum HBV DNA with persistence of HBsAg and HBeAg.  This 
phase is what is commonly referred to as “typical” HBeAg-positive chronic hepatitis B, 
and is also variable in duration and severity.  If severe and prolonged, HBeAg positive 
chronic hepatitis B can lead to progressive hepatic fibrosis and cirrhosis.  If milder in 
course or shorter in duration, this phase can eventually resolve, leading to an inactive 
HBsAg carrier phase with minimal liver fibrosis or injury.  This transition from immune 
active to inactive chronic hepatitis B is usually marked by a sudden fall in HBV DNA 
levels and loss of HBeAg despite persistence of HBsAg (often referred to as HBeAg 
seroconversion because of development of anti-HBe).  The resulting inactive HBsAg 
carrier state is marked by the presence of normal ALT and AST levels with minimal 
activity (inflammation and necrosis) on liver biopsy, absence of HBeAg and presence of 
HBsAg. Once HBeAg has been cleared and HBV DNA falls to low levels, the disease 
becomes inactive or mild and does not progress further (6).  However, in some patients, 
the loss of HBeAg is not associated with complete resolution of disease and HBV DNA 
levels remain moderately elevated.  These patients have developed HBeAg-negative 
chronic hepatitis B, which can be progressive and is marked by fluctuating and moderate 
levels of HBV DNA in serum. Changes in the hepatitis B virus sequence as well as 
changes in immune reactivity appear to govern the course and outcome of chronic 
hepatitis B and whether the disease goes into long-term remission and an inactive 
carrier state or evolves into an HBeAg-negative chronic hepatitis B or continues in the 
HBeAg-positive chronic hepatitis B.  Furthermore, some patients with chronic HBV 
infection who become HBeAg negative, later also lose HBsAg and appear to be cured of 
the chronic viral infection.  In actuality, these patients usually harbor low levels of HBV 
DNA in an inactive state in the liver, but they usually are spared further hepatic injury or 
long-term consequences of the disease.    
 
These features of the natural history of chronic hepatitis B underlie the criteria for 
therapy of this disease and the endpoints of treatment (2, 7, 8).  Thus, therapy of typical 
HBeAg-positive chronic hepatitis B is generally aimed at clearance of HBeAg and 
attainment of the subsequent inactive carrier state with normal serum ALT levels and 
inactive liver histology.  Treatment of HBeAg-negative chronic hepatitis B is generally 
aimed at long-term suppression of HBV DNA levels and improvements in serum ALT 
levels and liver histology.  Of course, clearance of HBsAg is a much more desired 
endpoint of therapy.  Unfortunately, loss of HBsAg is rarely achieved, at least with 
therapy for a limited period of time and with current treatment options.  Nevertheless, 
endpoints short of loss of HBsAg have to be considered surrogate endpoints of therapy 
and of uncertain long-term benefit (9).  Thus, while many patients who clear HBeAg 
during antiviral therapy of hepatitis B seem to attain a long-term remission in disease, a 
proportion do not improve or later relapse either re-developing HBeAg or evolving into 
HBeAg-negative chronic hepatitis B with fluctuating moderate levels of HBV DNA, 
elevations in serum aminotransferase levels, and inflammation, necrosis and potentially 
progressive fibrosis on liver biopsy.   
 
Thus, the aim of antiviral therapy of chronic hepatitis B is to achieve control of HBV 
replication and improve disease activity.  Suppression of HBV DNA to a low level is 
usually followed by improvements in serum ALT and AST and amelioration of the 


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underlying hepatic inflammation and hepatocellular injury. This often follows loss of 
HBeAg induced by antiviral therapy, but most reliably occurs with loss of HBsAg.  
 
There are two forms of licensed treatment for chronic hepatitis B: parenterally 
administered peginterferon and orally administered nucleos(t)ide analogues (lamivudine 
adefovir dipvoxil, telbivudine, entecavir and tenofovir disoproxil fumarate [tenofovir DF]). 
The mechanisms of action of these two forms of therapy are quite different, as are the 
route of administration and frequency and severity of side effects (10, 11).  Mainly 
because of their ease of administration and lack of side effects, the nucleos(t)ide 
analogues have become the preferred means of treatment.  Nevertheless, several 
prospective trials have shown that the rate of response, defined by HBeAg loss, to a 48 
week course of peginterferon is significantly higher than that to a 48 week course of 
nucleos(t)ide analogues; with rates of HBeAg loss at one year ranging from 12-24% for 
nucleos(t)ide analogues compared to rates of 30-35% with peginterferon (12-16).  
However, the nucleos(t)ide analogues are typically administered long-term rather than 
for one year only; and rates of clearance of HBeAg during nucleos(t)ide therapy typically 
increase with more prolonged therapy.  In contrast, the expense and side effects of 
peginterferon makes long-term therapy impractical.  Thus, it appears that rates of 
clearance of HBeAg achieved with peginterferon can be achieved with the better 
tolerated nucleos(t)ide analogues with longer courses of treatment.  Nevertheless, the 
rates of clearance of HBeAg after stopping peginterferon have not been assessed 
adequately and long-term follow up of 48 weeks of therapy with peginterferon may be 
associated with a gradual rise in rates of loss of HBeAg.  These factors make it difficult 
to discern whether peginterferon has any benefit above and beyond what can be 
achieved with the oral nucleos(t)ide analogues.  Furthermore, long-term therapy with 
nucleos(t)ide analogues is often associated with a high rate of improvement in liver 
histology, HBV DNA suppression and normalization of ALT even without change in 
HBeAg status.  The long-term improvement in these features is particularly evident in 
therapy of patients with HBeAg-negative chronic hepatitis B (17, 18), in which 
peginterferon therapy is associated with only a modest long-term effect on HBV DNA 
and ALT levels (19). 
 
A feature of peginterferon treatment that is distinctly greater than with nucleos(t)ide 
analogue therapy is the loss of HBsAg. Thus, in studies of HBeAg-positive chronic 
hepatitis B with a one-year course of peginterferon, rates of loss of HBsAg have ranged 
from 3% to 7%, whereas loss of HBsAg with a 48 week course of nucleos(t)ide 
analogues is <1% to 3% (12-16).  Furthermore, long-term follow up of patients who have 
become HBeAg-negative after interferon therapy has shown that the majority of these 
patients eventually become HBsAg negative as well (20).  This gradual loss of HBsAg is 
greater than occurs spontaneously and appears to be a special characteristic of 
responses to peginterferon therapy.  Emerging data suggests that ultimately prolonged 
suppression of viral replication with a nucleos(t)ide analogue leads to HBsAg loss. In 
one study loss of HBsAg after 1 year of tenofovir DF was observed in 3% of those 
treated for HBeAg-positive CHB and this figure increased to 6% after 2 years of therapy 
(only in genotypes A and D).  In another study with adefovir for 4-5 years for HBeAg-
negative CHB, HBsAg clearance occurred in a third of the patients followed for up to 5 
years after stopping therapy.  It is unknown whether even longer duration of therapy with 
nucleoside(t)ide analogues will result in ever increasing HBsAg loss or whether the rate 
of loss will level off.   
 


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Thus, the advantages of nucleos(t)ide analogue therapy are the ease of administration, 
the lack of significant side effects and the consistent suppression of HBV DNA that can 
be achieved, particularly with the newer agents such as tenofovir DF and entecavir. 
While emergence of drug resistance can limit the efficacy of oral agents, a low rate of 
antiviral resistance (1% or less even with prolonged therapy for 4 to 5 years), is seen 
with entecavir and tenofovir DF, reflective of their greater potency and higher genetic 
barrier to resistance.  As a consequence 80-90% of patients treated long-term with these 
agents achieve rates of marked suppression of HBV DNA levels and normal ALT levels. 
The advantage of peginterferon therapy is that it is administered for a limited period (6 to 
12 months) and results in loss of HBsAg in a significant proportion of patients.  Previous 
studies have shown that a one-year course of combination therapy of peginterferon and 
nucleos(t)ide analogue does not yield a higher response rate than a one-year course of 
either agent alone (21).  However, these studies have been limited by the use of a 
nucleos(t)ide analogue with high risk of resistance (e.g. lamivudine)  and a relatively 
short course of treatment. Thus, an obvious question is whether the combination of a 
limited course of peginterferon (6 or 12 months) with long-term therapy with a potent 
nucleos(t)ide analogue (tenofovir DF or entecavir for at least 4 years) will provide a 
higher rate of loss of HBsAg and ability to stop therapy without relapse.  This clinical trial 
compares the efficacy of peginterferon plus a potent nucleotide analogue, tenofovir DF, 
for 24 weeks followed by monotherapy with tenofovir DF for a further 3.5 years to the 
efficacy of that same potent nucleotide analogue, tenofovir DF, given for a full 4 years. 
The primary measure of outcome will be HBsAg loss in serum 240 weeks after starting 
antiviral therapy. 
 
2. Study objectives 
To define the role of limited duration peginterferon alfa-2a in the presence of tenofovir for 
treating people with chronic hepatitis B by: 
• 
 Evaluating “off treatment” sustained responses following combination therapy 
consisting of peginterferon alfa-2a plus tenofovir DF versus tenofovir DF 
monotherapy. 
• 
Comparing the on-treatment efficacy of initial treatment with combination therapy 
consisting of peginterferon alfa-2a plus tenofovir DF versus tenofovir DF 
monotherapy. 
 
2.1. Primary Endpoint 
HBsAg loss at week 240.  
 
2.2. Secondary endpoints 
2.2.1. At week 192 : 
a. Cumulative HBsAg loss. 
b. HBeAg loss. 
c. HBsAg seroconversion. 
d. HBeAg seroconversion.  
e. ALT normalization (males ≤30 U/L, females ≤20 U/L). 
f. 
ALT ≤38 U/L (males), ≤25 U/L (females) corresponding to approximately 1.25 
xULN.  
g. HBV DNA <1000 IU/mL. 
h. HBV DNA <20 IU/mL (Lower limit of quantification [LLOQ]) of COBAS 
Ampliprep/COBAS TaqMan HBV v2.0 test). 
i. 
Absence of detectable antiviral drug-resistance HBV mutations.  
j. 
Sustained HBV DNA <1000 IU/mL  


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2.2.2.  Sustained end of follow-up responses at week 240 
a. Cumulative HBsAg loss. 
b. HBeAg loss. 
c. HBsAg seroconversion.  
d. HBeAg seroconversion. 
e. ALT normalization (males ≤30 U/L, females ≤20 U/L). 
f. 
HBV DNA <1000 IU/mL. 
g. HBV DNA <20 IU/mL (LLOQ of COBAS Ampliprep/COBAS TaqMan HBV v2.0 
test). 
 
2.2.3.  Sustained off treatment (36 and 48 weeks after end of treatment) responses  
a. ALT ≤38 U/L (males), ≤25 U/L (females) corresponding to approximately 1.25 
xULN.  
b. HBV DNA <1000 IU/mL.  
c. HBV DNA <1000 IU/mL AND ALT ≤38 U/L (males), ≤25 U/L (females) 
corresponding to approximately 1.25 xULN.  
d. HBV DNA <20 IU/mL (LLOQ of COBAS Ampliprep/COBAS TaqMan HBV v2.0 
test). 
 
2.2.4. Sustained off treatment (36 and 48 weeks after end of treatment) responses 
in participants with low end of treatment HBsAg levels (<2000 IU/mL) versus 
participants with high end of treatment HBsAg levels (≥2000 IU/mL)  
a. Cumulative HBsAg loss. 
b. HBeAg loss. 
c. HBsAg seroconversion.  
d. HBeAg seroconversion. 
e. ALT normalization (males ≤30 U/L, females ≤20 U/L). 
f. 
HBV DNA <1000 IU/mL. 
g. HBV DNA <20 IU/mL (LLOQ of COBAS Ampliprep/COBAS TaqMan HBV v2.0 
test). 
 
2.2.5. Sustained off-treatment (36 and 48 weeks after end of treatment) responses 
in participants with a substantial drop of HBsAg levels (≥1 log from baseline to 
end of treatment) versus participants who did not have substantial drop of HBsAg 
levels (<1 log from baseline to end of treatment)  
a. Cumulative HBsAg loss. 
b. HBeAg loss. 
c. HBsAg seroconversion. 
d. HBeAg seroconversion. 
e. ALT normalization (males ≤30 U/L, females ≤20 U/L). 
f. 
HBV DNA <1000 IU/mL. 
g. HBV DNA <20 IU/mL (LLOQ of COBAS Ampliprep/COBAS TaqMan HBV v2.0 
test). 
 
2.2.6. Sustained off-treatment (36 and 48 weeks after end-off treatment) responses 
in participants with end of treatment HBsAg level <2000 IU/mL and HBV DNA 
below 1000 IU/mL versus participants with end of treatment HBsAg levels ≥2000 
IU/mL and HBV DNA ≥1000 IU/mL 
a. Cumulative HBsAg loss. 
b. HBeAg loss. 


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c. HBsAg seroconversion.  
d. HBeAg seroconversion. 
e. ALT normalization (males ≤30 U/L, females ≤20 U/L). 
f. 
HBV DNA <1000 IU/mL. 
g. HBV DNA <20 IU/mL (LLOQ of COBAS Ampliprep/COBAS TaqMan HBV 
v2.0 test). 
 
2.2.7. Treatment failure- Cumulative rates of primary nonresponse, partial virologic 
response and confirmed virologic breakthrough 
 
2.2.8. Rate of discontinuation of treatment due to adverse events. 
 
2.2.9. Rates of adverse events and serious adverse events. 
 
3. Study design 
This is a randomized (1:1) parallel group design trial comparing outcomes of treatment 
with (i) monotherapy, i.e., tenofovir DF 300 mg daily for 192 weeks (4 years) and (ii) 
combination therapy, i.e., peginterferon alfa-2a 180 µg weekly for 24 weeks plus 
tenofovir DF 300 mg daily for 192 weeks (4 years).  Enrolled participants will be stratified 
by HBeAg status (positive/negative), known genotype (A vs. all others) and cirrhosis 
(present vs. absent).  After 192 weeks of treatment, participants meeting criteria for 
treatment discontinuation will stop treatment and be followed for up to 48 weeks (total 
duration of treatment and follow up is up to 240 weeks). Emtricitabine/tenofovir 
coformulated as Truvada, approved for treating HIV but not for treating HBV infection, 
will be offered to participants with primary nonresponse, partial virological response or 
confirmed virologic breakthrough.  
 
4. Study population 
4.1 Inclusion criteria 
1. 
Enrolled in the Hepatitis B Research Network (HBRN) Cohort Study or 
completed the necessary components of the Cohort baseline evaluation by the 
end of the baseline visit for this study. 
2. 
At least 18 years of age at the time of randomization (day 0). 
3. 
Chronic HBV infection as evidenced by at least one of the following: 
a. HBsAg positive result within 8 weeks prior to randomization and another 
time at least 24 weeks prior to randomization with no HBsAg negative 
result in between. 
b. HBsAg positive plus absence of detectable anti-HBc IgM in serum within 
8 weeks prior to randomization. 
c. HBsAg positive within 8 weeks prior to randomization and HBV DNA 
≥1,000 IU/mL on 2 occasions at least 24 weeks apart (can include result 
from screening visit within 8 weeks of randomization). 
d.  HBsAg positive within 8 weeks prior to randomization plus evidence of 
chronic hepatitis B infection as indicated by a liver biopsy within 144 
weeks of randomization. 
4. 
HBeAg positive or negative. 
5. 
Serum HBV DNA ≥1000 IU/mL on 2 occasions at least 4 weeks apart within 
the 32 weeks prior to randomization (can include result from screening visit 
within 8 weeks of randomization). 


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6. 
At least two elevated serum ALT levels (>45 U/L for males and >30 U/L for 
females) at least 4 weeks, and no more than 32 weeks apart with the second 
being within 8 weeks of randomization. 
7. 
Compensated liver disease, with total bilirubin ≤2 mg/dL (except if Gilbert’s 
syndrome), direct bilirubin ≤0.5 mg/dL, INR ≤1.5, and serum albumin ≥3.5 g/dL  
8. 
No evidence of HCC based upon alpha-fetoprotein (AFP) ≤20ng/mL within 8 
weeks prior to randomization: 
a. Participants who meet AASLD criteria for HCC surveillance must have 
negative liver imaging by ultrasound (US), computerized tomography (CT) 
or magnetic resonance imaging (MR) within 28 weeks of randomization 
as part of standard of care. 
b. Participants with AFP >20 ng/mL must be evaluated clinically with 
additional imaging and shown not to have HCC on CT or MRI.  
9. 
Liver biopsy  that shows findings consistent with chronic hepatitis B with the 
Modified Ishak histology activity index (HAI) ≥3 (necroinflammatory component 
only) or Ishak fibrosis score ≥1 or both, as assessed by the local consortium 
pathologist on review of a liver biopsy done within 144 weeks of randomization. 
Slides must be available for review by the local consortium pathologist and 
meet adequacy requirements. If the participant had received previous 
treatment for hepatitis B, the biopsy must have been done after discontinuation 
of treatment. 
10. 
Females of child bearing potential must agree to use an adequate method of 
contraception throughout the study and must have a negative pregnancy test 
immediately prior to the start of treatment. 
11. 
 Provide informed consent and agree to adhere to the requirements of the 
study. 
 
4.2 Exclusion criteria 
1. Serum ALT >450 U/L for males and >300 U/L for females (participants are 
eligible for re-screening if ALT levels fall to the range of eligibility).  
2. Treatment with interferon or nucleos(t)ide analogues for hepatitis B within 48 
weeks of randomization. 
3. More than 48 weeks of therapy with nucleos(t)ide analogues for hepatitis B at 
any time in the past. 
4. History of hepatic decompensation including, but not limited to, ascites, variceal 
bleeding, or hepatic encephalopathy. 
5. Known allergy or intolerance to any of the study medications. 
6. Females who are pregnant or breastfeeding.  
7. Previous organ transplantation including engrafted bone marrow transplant. 
8. Any other concomitant liver disease, including hemochromatosis or hepatitis C or 
D. Non-alcoholic fatty liver disease (NAFLD) with steatosis and/or mild to 
moderate steatohepatitis is acceptable but NALFD with severe steatohepatitis is 
exclusionary.  
9. Positive anti-HIV (test to be completed within 8 weeks prior to randomization). 
10. Renal insufficiency with calculated (by MDRD method) creatinine clearance <60 
mL/min within 8 weeks prior to randomization. 
11. Platelet count <90,000 /mm3, hemoglobin <13 g/dL (males) or <12 g/dL 
(females), absolute neutrophil count <1500 /mm3 (<1000/mm3 for African-
Americans) within 8 weeks prior to randomization. 
12. History of alcohol or drug abuse within 48 weeks of randomization. 
13. Pre-existing psychiatric condition(s), including, but not limited to: 


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a. Current moderate or severe depression as determined by the study 
physician. 
b. History of depression requiring hospitalization within past 10 years. 
c. History of suicidal or homicidal attempt within the past 10 years. 
d. History of severe psychiatric disorders including, but not limited to, 
schizophrenia, psychosis, bipolar disorder as determined by a study 
physician. 
14. History of immune-mediated disease, or cerebrovascular, chronic pulmonary or 
cardiac disease associated with functional limitation, retinopathy, uncontrolled 
thyroid disease, poorly controlled diabetes or uncontrolled seizure disorder, as 
determined by a study physician. 
15. Any medical condition that would, in the opinion of a study physician be predicted 
to be exacerbated by therapy or that would limit study participation. 
16. Any medical condition requiring, or likely to require, chronic systemic 
administration of corticosteroids or other immunosuppressive medications during 
the course of this study. 
17. Evidence of active or suspected malignancy, or a history of malignancy within the 
last 144 weeks prior to randomization (except adequately treated carcinoma in 
situ or basal cell carcinoma of the skin). 
18. Expected need for ongoing use of any antivirals with activity against HBV during 
the course of the study. 
19. Participation in any other clinical trial involving investigational drugs within 30 
days of randomization or intention to participate in another clinical trial involving 
investigational drugs during participation in this study. 
20. Any other condition that in the opinion of a study physician would make the 
participant unsuitable for enrollment or could interfere with the participant 
participating in and completing the study. 
 
5. Study drugs and drug management 
5.1. Dosage and administration  
Participants will be randomly assigned to receive one of the following treatments during 
the treatment period of the study:  
• 
Treatment A: Tenofovir DF 300 mg by mouth once daily for 192 weeks. 
• 
Treatment B: Peginterferon alfa-2a 180 µg by subcutaneous injection once 
weekly in combination with tenofovir DF 300 mg by mouth once daily for 24 
weeks followed by tenofovir DF 300 mg once daily for 168 weeks (192 weeks 
total therapy). 
 
All participants will be instructed to take one tablet of tenofovir DF once daily without 
regards to meals.  Participants in treatment arm B will also be instructed to take 180 µg 
of peginterferon alfa-2a subcutaneously once weekly.  Participants in treatment arm B 
will be instructed to inject the peginterferon alfa-2a on the same day each week.  
 
5.2. Tenofovir disoproxil fumarate 
5.2.1 General information 
Tenofovir disoproxil fumarate (tenofovir DF) is a prodrug of tenofovir.  It is an acyclic 
nucleotide phosphonate analogue of adenosine 5 monophosphate.  The medication is 
stored at room temperature. 
 
5.2.2 Pharmacokinetic considerations 


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Tenofovir DF is well absorbed from the gastrointestinal tract and after being taken up 
intracellularly is hydrolyzed rapidly to tenofovir and phosphorylated by cellular nucleotide 
kinases to the active form, tenofovir diphosphate.  Tenofovir diphosphate competes with 
the natural intracellular deoxyadenosine triphosphate for uptake into the nascent viral 
DNA molecule and once incorporated causes DNA chain termination. Tenofovir 
diphosphate may also interfere with the HBV DNA polymerase by binding to the active 
catalytic site.  The intracellular half-life of tenofovir is prolonged and is in excess of 60 
hrs.  The half-life of tenofovir in serum is about 17 hours following a single dose.  
Multiple dose pharmacokinetics suggests that the median steady state tenofovir Cmax 
values are 355 mg/L [0.33 µg/mL] after 48 weeks.  Food does not affect absorption or 
pharmacokinetics. No demographic variables appear to affect tenofovir pharmaco-
kinetics across either healthy participants or participants infected with HIV or HBV.  
Tenofovir is excreted unchanged in the urine and dose adjustments are needed in 
participants with renal insufficiency.     
 
Dose adjustments are required for creatinine clearance (CrCl) of <50 mL/min. 
 
 
Creatinine Clearance (mL/min) 
Hemodialysis 
>50 
30-50 
10-29 
Recommended 
300 mg dosing 
interval 
Every 24 hours 
Every 48 hours 
Every 72 to 96 
hours 
Every 7 days or 
after a total of 
approximately 12 
hours of dialysis 
  
Only when there is moderate CrCl (30-50 mL/min) or severe reduction in CrCl 
(<30mL/min) is there the chance for drug toxicity after a single 300 mg dose. 
 
In vitro, tenofovir DF at expected concentrations with once a day dosing does not inhibit 
the metabolizing ability of major human cytochrome P-450 isoforms (CYP1A2, CYP2C9, 
CYP2C19, CYP2D6, and CYP3A4) responsible for phase I metabolism of most drugs. 
 
Drug interactions potentially could occur with other drugs which are eliminated by 
proximal tubular secretion e.g. cidofovir, acyclovir and other members of this group of 
agents.  Such a drug interaction may result in increased blood levels of tenofovir DF or 
the competing agent.  Similarly there may be some interactions with drugs used in the 
treatment of HIV e.g. didanosine, atazanavir and lopenavir/ritonavir. 
 
There is no substantial effect of TDF on methadone, estrogens or birth control pill 
pharmacokinetics. 
 
5.2.3 Safety 
Tenofovir DF is freely excreted unchanged by the kidneys by glomerular filtration and 
tubular secretion.  High levels of tenofovir DF in renal tubules may interfere with renal 
function in a dose-dependent manner. Reports of hypophosphatemia, renal tubular 
toxicity and renal failure exist. This tubular toxicity manifests as renal tubular acidosis, a 
Fanconi-like syndrome or nephrogenic diabetes insipidus (22). Probably as a 
consequence of the nephrotoxic effects of tenofovir DF, osteomalacia has been reported 
in young macaques given 25 times the recommended dose. The osteomalacia observed 
may have been the result of chronic hypophosphatemia caused by tubular phosphate 
leakage. For this reason, use of tenofovir DF currently is not recommended in children.   
 


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To date most studies examining bone density in participants on prolonged therapy with 
tenofovir DF have been in participants with HIV infection. Osteopenia and osteoporosis 
have been reported but with no significant difference in the frequency of these 
complications in participants with HIV who are and who are not taking tenofovir.  
 
Reproductive Toxicity: Tenofovir DF is a Pregnancy Category B drug. No adverse effects 
on embryo-fetal development in rats were observed with long-term, high-dose therapy; 
nor were there adverse effects on growth, development, and behavior. In this study, 
females of childbearing potential will be enrolled only if they agree to use effective 
contraception during therapy and pregnancy testing will occur at every visit during the 
peginterferon treatment phase. 
 
5.3 Peginterferon-alfa-2a 
5.3.1 General description 
Peginterferon alfa-2a is a covalent conjugate of recombinant alfa-2a interferon with a 
single branched molecule of polyethylene glycol with a molecular weight of 
approximately 40,000 daltons. Peginterferon alfa-2a is produced using recombinant DNA 
technology and contains 180 µg/1.0 mL in vial form and the same amount per 0.5 mL in 
a prefilled syringe. The drug must be kept refrigerated at +4C until use.  
 
Interferon inhibits viral replication by inducing an antiviral state in cells.  Interferon does 
not enter the hepatocyte, but rather binds to specific receptors on the cell surface, which 
initiates intracellular signaling that leads to rapid activation of multiple “interferon-
stimulated genes (ISGs); the encoded proteins of these genes inhibit viral replication in 
infected hepatocytes by multiple mechanisms (including inhibition of viral protein 
synthesis and breakdown of viral RNA).  Peginterferon alfa-2a also has 
immunomodulatory activity that is thought to be important in obtaining a virological 
response. Steady-state serum concentrations of peginterferon alfa-2a are reached within 
5 to 8 weeks using once weekly dosing.  The mean terminal half-life after subcutaneous 
dosing is 160 hours compared to 5 hours for standard alpha interferon. 
 
5.3.2 Pharmacokinetic considerations  
In participants with end-stage-renal-disease undergoing hemodialysis, there is a 25% to 
45% reduction in clearance of peginterferon alfa-2a. The effect of milder renal 
impairment has not been studied but it is advised that in participants with impaired renal 
function, signs and symptoms of interferon toxicity should be closely monitored.  It is 
also recommended that peginterferon alfa-2a be used with caution in participants with 
creatinine clearance < 50 mL/min. 
 
There is no known effect of peginterferon alfa-2a on the pharmacokinetics of drugs 
metabolized by the cytochrome P-450 system. There are no known clinically significant 
interactions with nucleos(t)ide analogue therapy, but a phase IV registration trial of 
peginterferon alfa-2a and telbivudine was prematurely discontinued due to a higher than 
anticipated incidence of peripheral neuropathy.  
 
5.3.3. Safety 
As with standard alpha interferon, treatment with peginterferon alfa-2a is associated with 
many troublesome and occasionally serious, or even life-threatening, side effects.  Dose 
discontinuation has been reported in 6% to 9% and dose modification in 31% to 47% of 
participants treated in the peginterferon alfa-2a registration trials for hepatitis B.  The 
most frequent causes of dose adjustment were laboratory abnormalities such as 


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thrombocytopenia or leukopenia.  These side effects are particularly common in patients 
with advanced liver disease and hypersplenism.  Peginterferon alfa-2a is contraindicated 
in participants with decompensated cirrhosis due to the possibility of serious infections, 
flares of disease, and worsening decompensation. In this study, patients with any clinical 
or laboratory features suggestive of hepatic decompensation will not be enrolled. 
 
The majority of clinical experience in the use of peginterferon alfa-2a has been in chronic 
hepatitis C in which peginterferon is combined with ribavirin.  In the few studies of 
peginterferon alfa-2a in chronic hepatitis B it has appeared that side effects are less 
frequent than in chronic hepatitis C.  The overall incidence of serious adverse events 
was less in studies in hepatitis B (4%-5%) than in those with hepatitis C (7% to 16%), 
and fewer drug withdrawals were reported (6% to 8% versus 17% to 33%, respectively) 
despite similar doses and durations of therapy.  Depression was also less frequently 
reported in studies done in hepatitis B (4%) than hepatitis C (22%, p < 0.001). 
 
Peginterferon should be avoided in participants with other serious co-morbid illnesses, 
including, but not limited to, coronary artery disease, cerebrovascular disease, serious 
autoimmune conditions and severe depression.  
 
Pregnancy:   
Peginterferon alfa-2a is a Pregnancy Category C drug that has not been adequately 
evaluated in humans for its teratogenic effect. Standard interferon has been shown to 
increase the rate of abortion in Rhesus monkeys when given approximately 20 to 500 
times the human weekly dose.  Interferon, however, is highly species specific in its 
effects and animal studies may not reliably reflect the potential of side effects in humans.  
There have been no adequate and well-controlled studies of peginterferon alfa-2a in 
pregnant females. Therefore, in this study, females of childbearing potential will be 
enrolled only if they agree to use effective contraception during therapy and pregnancy 
testing will occur at every visit during the peginterferon treatment phase. 
 
5.4. Administration and drug accountability  
Study drugs (peginterferon alfa-2a, tenofovir DF, and emtricitabine/tenofovir) will be 
shipped to study sites from the drug distribution center. Staff at each site will be 
responsible for drug accountability.  This will include documenting drugs received, study 
drug dispensed to participants, used and unused study drug returned, and accounting of 
any drug destroyed by the site. An accurate and up-to-date accountability log will be 
maintained by each site.    
 
5.5. Concomitant medications   
All concomitant medications (prescription and non-prescription) being taken by each 
participant will be queried and recorded by the study coordinator at each visit.   
 
5.6. Prohibited medications  
Use of the following medications is prohibited while participants are on study drugs: 
1. Antivirals with activity against HBV, including famciclovir or valacyclovir.  The 
need for ongoing use of these antivirals would be exclusionary at study entry, but 
allowed if medically indicated and prescribed during the course of the study.   
2. Nephrotoxic agents including aminoglycoside antibiotics, amphotericin, cidofovir, 
and foscarnet. 
3. Competitors of renal excretion such as probenecid and sulfinpyrazone. 
4. Systemic chemotherapeutic agents (i.e., cancer treatment medications). 


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5. Systemic corticosteroids. The need for ongoing use of systemic corticosteroids 
would be exclusionary at study entry, but would be recorded as a concomitant 
medication if medically indicated and prescribed during the course of the study.   
6. Any investigational agents. 
7. Use of growth factors such as GCSF, erythropoietin, and eltrombopag. 
 
6. Study procedures 
6.1. Study enrollment 
Participants thought to be eligible for participation will be asked to give their consent to 
participate by discussions with study physicians and coordinators and by signing a 
current consent form approved by the IRB/REB at that institution.  Participants will be 
required to sign the consent form before any study procedures are performed. 
They will then undergo the screening (8 weeks prior to randomization) procedures, 
including medical history, physical examination and blood tests as summarized in the 
Time and Event chart (Appendix 3).  Once eligibility is confirmed, they will complete pre-
randomization tests and then be randomly assigned (at baseline visit, day 0) to one of 
the two treatment groups using a system established by the Data Coordinating Center 
(DCC). Patients who are not currently enrolled in the HBRN Cohort study may be 
enrolled concurrently with the screening visit for this trial, or if they choose not to enroll 
into the Cohort Study, the necessary components on the Cohort baseline evaluation will 
be completed prior to enrolling in this study at the clinical trial screening or baseline visit. 
 
6.2. Pre-randomization (screening) assessment 
All participants are required to have a liver biopsy that is adequate for assessment within 
144 weeks of randomization.  The pre-treatment biopsies will be read by the local 
consortium pathologist, judged with respect to adequacy for assessing stage and grade, 
and whether it meets histologic criteria for entry. All slides will be re-reviewed centrally 
for subsequent data analysis.  
 
The following assessments must be obtained within 8 weeks (56 days) prior to 
randomization. 
1. Written informed consent. 
2. Detailed medical history. 
3. Physical examination, including pulse, blood pressure, temperature. 
4. Limited clinical evaluation including anthropometric measures. 
5. Depression assessment. 
6. If baseline evaluation for Cohort Study is combined with trial screening visit, 
complete the Cohort Screening Log and Baseline Evaluation forms (coordinator, 
participant, and investigator). 
7. Blood tests including CBC with differential, routine biochemical tests (including 
ALT, AST, total bilirubin, direct bilirubin, albumin, total protein, alkaline 
phosphatase, creatinine [including calculated CrCl], serum uric acid, BUN, 
calcium, phosphate, vitamin D, triglycerides, glucose, TSH, PT/INR, alpha-
fetoprotein, anti-HCV and anti-HDV (if not available within the prior 144 weeks), 
anti-HIV, and HBV serologies  
8. Urinalysis. 
9. Pregnancy test for females of childbearing age.  
10. Blood samples for qualitative HBsAg and HBeAg, anti-HBs, anti-HBe, HBV DNA, 
HBV precore/BCP, and antiviral resistance. Plasma and serum samples will be 
stored at each visit. 


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11. Blood samples for HBV genotype and/or subtype will be obtained if not available 
from samples drawn for the HBRN Cohort study. 
12. Dual energy X-ray absorptiometry (DEXA) scan for bone density if clinically 
indicated (as standard of care). 
13. A CT or MRI is required for patients with alpha fetoprotein greater than 20 ng/mL 
as clinically indicated to rule out HCC.   
14. In participants with diabetes or hypertension, a retinal examination will be 
performed as standard of care unless done in the previous 48 weeks. 
 
There are two ALT levels and HBV DNA levels required to qualify for randomization, with 
the most recent for ALT being within 8 weeks prior to randomization and the most recent 
for HBV DNA being within 32 weeks of randomization.   
 
6.3. Baseline visit (day 0) 
The baseline visit (day 0) will coincide with randomization and the start of therapy. The 
baseline visit will consist of:  
1. Limited clinical evaluation. 
2. Review of adverse events and concomitant medications. 
3. Drug dispensing; instructions on their use, including education on self-injection 
with peginterferon alfa-2a (if appropriate). 
4. Questionnaires (symptoms, quality of life, health behaviors, and fatigue). 
5. Depression assessment. 
6. Blood tests including CBC with differential, hepatic and renal panel, albumin, total 
protein, alkaline phosphatase, and PT/INR.  
7. Urinalysis, urine creatinine, and urine phosphate. 
8. Pregnancy test for females of childbearing potential. 
9. A blood sample for storing serum and plasma for future research. 
10. Blood samples for qualitative HBeAg, anti-HBe, quantitative HBsAg, quantitative 
HBeAg, and HBV DNA testing. 
11. Blood sample (with consent) for DNA extraction and genetic testing will be drawn 
if not obtained as part of the Cohort Study.  This may be collected at a future visit 
if not obtained at baseline. 
 
6.4. On-Treatment assessments 
After randomization, participants will be seen in follow up at 4-week intervals for the first 
12 weeks and then at 12 week intervals until therapy is completed, as shown in the Time 
and Event Chart (Appendix 3).  For participants having side effects related to treatment 
or adherence issues, more frequent visits can be undertaken at the discretion of the 
study physician.  These visits will be conducted as an “Unscheduled Visit” and 
tests/procedures performed will be at the discretion of the study physician (with the 
exception of adverse events to be managed per guidelines specified in the protocol or 
manual of operations, i.e. hepatitis flare or hypophosphatemia).  
1. Each outpatient visit will include assessment of compliance, adverse events 
reporting, vital signs, weight, symptoms evaluation, record of concomitant 
medications, drug dispensing, and blood testing as detailed in the Time and Event 
Chart (Appendix 3). 
2. Symptom questionnaire at each visit. 
3. Depression assessments at weeks 12, 24, 36, 48, and 96. 
4. Fatigue questionnaire at weeks 24 and 96. 
5. Health Behavior and quality of life questionnaires at weeks 48, 96, and 144. 


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6. Blood will be drawn for CBC with differential at each visit until week 36 and then 
CBC without differential at week 48, 96, and 144. 
7. Hepatic panel (AST, ALT, total bilirubin) at each visit. 
8. A renal panel (creatinine, calculated creatinine clearance, phosphate, blood urea 
nitrogen, and calcium) at every visit from week 12 on. 
9. TSH at weeks 12 and 24.  
10. Glucose and triglycerides at week 24. 
11. There will be a PT/INR, serum uric acid, and other liver tests (albumin, total 
protein, alkaline phosphatase, direct bilirubin) at weeks 48, 96, and 144.  
12. There will be a urinalysis done at weeks 48, 96, and 144. 
13. A fasting urine creatinine and phosphate will be done at week 96. 
14. For females of childbearing age, adherence to contraception will be reviewed and 
a pregnancy test repeated at each visit during the peginterferon treatment phase. 
15. Qualitative HBeAg (in patients who were HBeAg-positive at baseline visit) and 
HBsAg at weeks 48 and 96.  If there is HBeAg or HBsAg loss then anti-HBe or 
anti-HBs will be tested. 
16. Qualitative HBeAg and anti-HBe (regardless of HBeAg status at the baseline visit) 
at weeks 144 and 180.   
17. Qualitative HBsAg at week 180. 
18. Quantitative HBsAg and HBeAg will be tested at every visit from week 12 on.  
19. HBV DNA will be drawn at every visit. 
20. A blood sample for storing serum and plasma for future research will also be 
drawn. 
21. Antiviral resistance testing at weeks 48, 96, and 144. 
22. Ultrasound exam (If clinically indicated, per AASLD guidelines, done as standard 
of care) at weeks 48, 96, and 144. 
23. Fibroscan (if available) no earlier than week 180 visit and no later than week 192 
visit 
 
6.4.1 Review criteria for discontinuing treatment and resumption of treatment and 
post treatment follow up schedule 
At the week 180 visit, the scheduled visit prior to the visit at which eligible participants 
are scheduled to discontinue treatment, a study physician will review the rationale for 
antiviral withdrawal, criteria for treatment discontinuation, potential benefits and risks, 
criteria for resuming treatment, and the post treatment follow up schedule with the 
participants. The study PI will document this discussion in the participant’s record.  The 
participant will be provided with a fact sheet that will be reviewed by a study physician 
and a signed copy maintained in the study record. Participants should be reminded to 
bring all remaining study medication to the next visit (week 192). Blood will be drawn for 
qualitative HBeAg, anti-HBe, and HBsAg testing so results are available at week 192. 
Eligibility to discontinue treatment will be reconfirmed by the study PI on week 192. 
 
6.5 End of Treatment (Week 192) 
At week 192, all participants will complete the following: 
1. Physical exam. 
2. Assessment of adverse events, concomitant medications and adherence 
3. Questionnaires (symptoms, quality of life, health behaviors, and fatigue) 
4. Depression assessment. 
5. Blood will be drawn for CBC, hepatic panel (including albumin, total protein, 
alkaline phosphatase), renal panel, serum uric acid, PT/INR, anti-HIV, qualitative 
HBeAg, anti-HBe, anti-HBs, HBsAg, and HBV DNA.  A sample of blood will be 


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stored for eventual assessment of HBeAg and HBsAg concentration, 
precore/BCP analysis, and antiviral resistance testing.   
6. A blood sample for storing serum and plasma for future research will also be 
drawn 
7. Urinalysis and fasting urine creatinine and phosphate. 
8. Ultrasound exam (if clinically indicated, per AASLD guidelines, done as standard 
of care). 
9. Fibroscan if available and not performed at, or since, the week 180 visit 
.  
At week 192 (year 4), participants who meet study criteria for discontinuing therapy 
(section 6.5.1) will have treatment stopped.  
 
6.5.1 Eligibility criteria for discontinuing treatment at week 192 (participants must 
meet all criteria)  
Participants will be discontinued from treatment if they meet all of the following criteria as 
determined based on laboratory results at the week 180 visit and any additional test 
results and clinical assessment up until the week 192 visit: 
1. HBV DNA <1000 IU/mL for the previous 24 weeks (i.e. starting at or before week 
156 and continuing through week 180). 
2. No cirrhosis (Ishak score 5 or 6) on baseline biopsy 
3. Normal indices of liver function (CTP =5), albumin ≥3.8 g/dL, INR ≤1.3, direct 
bilirubin ≤0.5 mg/dL  
4. No clinical evidence of decompensation 
5. No clinical or radiologic evidence of portal hypertension  
6. Platelet count ≥120,000/mm3 
7. HBeAg-negative at baseline visit and confirmed at week 180, or HBeAg-positive 
at baseline visit with HBeAg loss at or before week 144 and confirmed at week 
180.  In either situation, there can be no HBeAg positive result at or after week 
144. 
8. HBsAg-negative (regardless of anti-HBe status), or if HBsAg-positive, HBeAg-
negative and anti-HBe-positive at week 180 
 
Participants who do not meet criteria for discontinuing treatment will continue 
treatment with tenofovir DF until Week 240 or end of the study. Tenofovir DF for the 
period Week 192 to Week 240 will be provided by the study. Follow up visits and testing 
will continue every 12 weeks (204, 216, 228) to week 240 or end of the study. If tenofovir 
DF will be continued beyond Week 240 or end of the study, medication must be obtained 
per standard of care. 
 
Participants who meet criteria for discontinuing treatment but continue treatment 
will have follow-up visits and testing per the schedule for participants who discontinue 
treatment. No study medications (Tenofovir DF) will be provided beyond Week 192 and 
any antiviral therapy must be obtained per standard of care. 
 
6.6 Post Treatment assessments (Appendix 4) 
1. Outpatient visits will occur at weeks 196, 200, 204, 208, 212, 216, 228, and 240 
for participants in both treatment groups. 
2. Laboratory testing (liver panel) plus telephone assessment can replace an 
outpatient visit at weeks 208 and 212 if ALT at the preceding assessment (week 
204 and week 208, respectively) is <300 U/L for men or <200 U/L for women and 
bilirubin is normal (total bilirubin <1.5 mg/dL or direct bilirubin <0.5 mg/dL) 


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3. Medical history and physical exam at week 240. 
4. Clinical evaluation at weeks 196, 200, 204, 208, 212, 216, and 228. 
5. Assessment of adverse events and concomitant medications at each visit. 
6. Questionnaires (quality of life, depression assessment, fatigue, and health 
behaviors) at week 240. 
7. Symptom questionnaire at each visit. 
8. CBC including platelets, alkaline phosphatase, albumin, total protein, and 
creatinine at week 240. 
9. Renal panel (creatinine, calculated creatinine clearance, phosphate, blood urea 
nitrogen, and calcium) at each study visit for participants who are on Tenofovir 
10. Hepatic panel (ALT, AST, albumin, total protein, alkaline phosphatase, total and 
direct bilirubin) at each visit. 
11. Urinalysis at week 240. 
12. PT/INR at weeks 196, 200, 204, 216, and 240. 
13. Blood samples for serum/plasma at each outpatient visit. 
14. Qualitative HBsAg, HBeAg, and anti-HBe at weeks 216 and 240. 
15. Anti-HBs and antiviral drug resistance testing at week 240. 
16. HBsAg quantification at weeks 204, 216, 228, and 240.  
17. HBeAg quantification at weeks 204, 216, 228, and 240.  
18. HBV DNA at each outpatient visit 
19. Ultrasound exam (If clinically indicated, per AASLD guidelines, done as standard 
of care) at week 240. 
20. Fibroscan (if available and obtained at, or since, the week 180 visit but not later 
than the week 192 visit) at week 240. 
 
6.7 Assessment of adherence 
At each study visit, study personnel will review the study drug dosing schedule with 
participants and counseling on adherence will be provided. At each study visit while on 
therapy, participants will be asked to return all bottles of tenofovir and used vials of 
peginterferon alfa-2a to document how much study medications were used. Serum drug 
levels may be measured on stored serum samples.  
 
6.8. Management of non-response 
Definition: Primary non-response is defined as a failure to achieve a >1-log10 IU/mL 
decline in HBV DNA after the first 24 weeks of treatment.  HBV DNA will be measured 
by the quantitative HBV DNA assay which will be reconfirmed with re-testing 4 weeks 
later (week 28). Compliance with study medications will be assessed and documented.  
Primary non-response is considered to be treatment failure. 
 
Management of non-response 
6.9.1. Reinforce compliance when non-response is initially suspected. 
6.9.2. Testing of Tenofovir DF levels may be performed (samples will be archived for 
analysis and not available in real-time).   
6.9.3. If serum HBV DNA report confirms that participant meets criteria for virological 
non-response, change to combination emtricitabine/tenofovir within 2 weeks of obtaining 
the week 28 result. 
6.9.4. Participants will be assessed at weeks 4, 8 and 12 and then every 12 weeks after 
initiation of rescue therapy to document the response. Thereafter, participants will be 
followed per protocol. 


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6.9.5. If serum HBV DNA is ≥1000 IU/mL by HBV DNA quantitation assay after 24 
weeks of rescue therapy, subsequent treatment will be altered at the discretion of the 
study physician. 
 
6.10 Management of a partial virological response 
Definition: A partial virological response is defined as a decrease of serum HBV DNA 
>1 log10 IU/mL by week 24 but a level ≥100,000 IU/mL confirmed on two consecutive 
visits (weeks 36 and 48).  A partial virological response is considered to be treatment 
failure. 
6.10.1. Reinforce compliance when partial response is initially suspected.  
6.10.2. Testing of Tenofovir DF levels may be performed (samples will be archived for 
analysis).   
6.10.3. If serum HBV DNA report confirms participant meets criteria for partial virologic 
response, change to combination emtricitabine/tenofovir within 2 weeks of obtaining the 
week 48 result  
6.10.4. Participants will be assessed at weeks 4, 8 and 12 weeks and then every 12 
weeks after initiation of rescue therapy to document the response. Thereafter, 
participants will be followed per protocol. 
6.10.5. If serum HBV DNA is ≥1000 IU/mL by HBV DNA quantitation assay by week 24 
of rescue therapy, subsequent treatment will be altered at the discretion of the study 
physician. 
 
6.11. Management of virological breakthrough  
Definition: Virological breakthrough is defined as a >1-log10 IU/mL increase in HBV 
DNA level from nadir or redetection of serum HBV DNA after disappearance that is 
confirmed on re-testing 4 weeks later in a participant verified to be medication compliant. 
If the re-test confirms virological breakthrough, a blood sample will be tested for 
genotypic resistance. 
 
6.11.1. Reinforce compliance when virological breakthrough is initially suspected.  The 
importance of compliance with study medication will be reinforced with study participants 
at each visit. 
6.11.2. Testing of Tenofovir DF levels may be performed (samples will be archived for 
analysis).   
6.11.3. Resistance mutations will be evaluated by sequencing stored samples.  
6.11.4. Selection of rescue therapy will be based upon the cross-resistance profile of the 
mutation(s) present when available. If unavailable, emtricitabine/tenofovir will be used. 
Rescue therapy should be started within 4 weeks of confirming the virological 
breakthrough. The time to start of rescue therapy may be adjusted depending upon the 
time required for resistance testing to be completed.  
6.11.5. Participants will be assessed at weeks 4, 8 and 12 weeks and then every 12 
weeks after initiation of rescue therapy to document the response.  Thereafter, 
participants will be followed per protocol. 
6.11.6. If serum HBV DNA is ≥1000 IU/mL by week 24 of rescue therapy, treatment will 
be changed at the discretion of a study physician. 
 
6.12 Definition and management of on-treatment hepatitis flares 
On-treatment hepatitis flare is defined as increase in ALT to ≥300 U/L for men and ≥200 
U/L for women AND >3 times baseline (day 0) value. Participants who meet criteria of a 
flare will be seen every 4 weeks until ALT decreases to <300 U/L for men and <200 U/L 
for women. Severe on-treatment hepatitis flare is defined as ALT ≥1000 U/L regardless 


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of gender. Participants who meet criteria of a severe flare will be seen every week until 
ALT decreases to <1000 U/L, at which point they will be evaluated every 4 weeks until 
ALT <300 U/L for men and <200 U/L for women and thereafter at scheduled visits per 
study protocol. Participants who experience hepatitis flares may continue treatment if 
total bilirubin is <2.0 mg/dL and direct bilirubin <1.0 mg/dL. Participants who experience 
severe hepatitis flares may continue treatment at the discretion of the investigator if total 
bilirubin is <2.0 mg/dL and direct bilirubin <1.0 mg/dL.  
 
6.13. End-of-treatment (prior to week 192) assessment  
6.13.1. Eligibility criteria for discontinuation of treatment prior to week 192   
Participants who meet either of the criteria below will be discontinued from treatment: 
 
• 
Grade IV toxicity (laboratory or clinical)  
• 
Hepatic decompensation while on peginterferon defined by: 
o Total bilirubin ≥2.0 mg/dL and direct bilirubin ≥1.0 mg/dL 
o Any clinical decompensation 
• 
Participant refuses to continue treatment/participation in study 
 
6.13.2. End of treatment assessment  
Participants who stop treatment early will complete assessments specified for the week 
192 visit (see section 6.5 and Appendix 3). 
 
Participants who discontinue treatment due to Grade IV toxicity or hepatic 
decompensation will continue to be followed until these events are resolved or stabilized, 
according to the post-treatment follow-up schedule. 
 
6.13.3. Follow-up visit schedule after week 192 
All participants who are eligible to stop treatment at week 192 will be seen at weeks 196, 
200, 204, 208, 212, 216, 228, and 240 (corresponding to weeks 4, 8, 12, 16, 20, 24, 36, 
and 48 post-treatment for those whose treatment is discontinued). This is the minimal 
follow up required. Laboratory testing (liver panel) plus telephone assessment can 
replace an outpatient visit at weeks 208 and 212 if ALT at the preceding assessment 
(week 204 and week 208, respectively) is <300 U/L for men or <200 U/L for women and 
bilirubin is normal (total bilirubin <1.5 mg/dL or direct bilirubin <0.5 mg/dL). Additional 
visits for safety monitoring should be included as needed. Participants who are not 
eligible to stop treatment at week 192 and who remain on treatment will be seen at 
weeks 204, 216, 228 and 240 (i.e., 12, 24, 36 and 48 weeks after week 192).  
Laboratory testing will be performed as outlined in Appendix 4. Blood samples for 
serum/plasma will be collected at each outpatient visit. 
 
6.14. Assessment and management of relapse after stopping therapy 
6.14.1. Definition of relapse 
Virological relapse: Persistent HBV DNA ≥1000 IU/mL during the follow-up period (on 
at least two samples at least 12 weeks apart, with one of them being more than 24 
weeks after stopping therapy) in HBeAg-positive or HBeAg-negative participants. 
Biochemical relapse will be defined as an elevated ALT (>30 U/L for females and >45 
U/L for males if normal at end of treatment or an increase of 1.5 X end of treatment level 
if abnormal at end of treatment) on at least two samples at least 12 weeks apart, with 
one of them being at least 24 weeks after stopping therapy. 
 


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An ALT flare will be defined as an ALT level ≥300 U/L for males or ≥ 200 U/L for 
females. 
 
These definitions will be used for data analyses, see section 6.14.2 for criteria to 
reinitiate treatment. 
 
Monitoring of participants 
• 
Participants with an increase in total bilirubin to ≥3 mg/dL or direct bilirubin to ≥1 
mg/dL or INR ≥1.3 (regardless of ALT and HBV DNA levels) must be reassessed 
as soon as possible and within 1 week for liver panel, PT/INR, CBC, and 
creatinine. The laboratory testing should continue every week until INR<1.3 and 
either total bilirubin <3 mg/dL or direct bilirubin <1 mg/dL. 
• 
Participants with an ALT >1000 U/L for both males and females (regardless of 
HBV DNA levels) must be reassessed as soon as possible and within 1 week. 
Thereafter, weekly monitoring of liver panel, bilirubin (total or direct), PT/INR, 
HBV DNA should continue until ALT ≤1000 U/L. 
• 
Participants with an ALT ≥300 U/L for males or ≥200 U/L for females (regardless 
of HBV DNA levels) must be reassessed within 1 week and thereafter, every 2 
weeks for liver panel, HBV DNA, bilirubin (total or direct), and PT/INR. The 
laboratory testing should continue until ALT <300 U/L for males or <200 U/L for 
females. 
• 
Participants with an ALT ≥150 U/L for males or ≥100 U/L for females (regardless 
of HBV DNA levels) must be reassessed within 4 weeks and thereafter every 4 
(±1) weeks for liver panel, HBV DNA, bilirubin (total or direct), and PT/INR. The 
laboratory testing should continue until ALT <150 U/L for males or <100 U/L for 
females. 
 
6.14.2. Criteria for treatment reinitiation in the Post-Treatment Follow up Period 
Tenofovir DF will be restarted for any one of the following: 
• 
Any one of the three criteria: INR ≥1.3, total bilirubin ≥3.0 mg/dL or direct bilirubin 
≥1.0 mg/dL, regardless of HBV DNA or ALT level. 
• 
Any clinical decompensation, regardless of HBV DNA or ALT level. 
• 
HBV DNA ≥10,000 IU/mL and ALT >1000 U/L (male or female) (i.e. only one ALT 
value >1000 U/L is needed to qualify). 
• 
HBV DNA ≥10,000 IU/mL and ALT ≥300 U/L for males, ≥200 U/L for females. A 
total of one HBV DNA ≥10,000 IU/mL and any three ALT values ≥300 U/L (male) 
or ≥200 U/L (female) over the 4-week (or longer) time frame are needed to 
qualify. Treatment will be resumed if the third ALT remains ≥300 U/L (male) or 
≥200 U/L (female).  
• 
HBV DNA ≥10,000 IU/mL and ALT ≥150 U/L for males or ≥100 U/L for females.  
A total of one HBV DNA ≥10,000 IU/mL and any three ALT values ≥150 U/L 
(male) or ≥100 U/L (female) over the 12 week (or longer) time period are needed 
to qualify. Treatment will be resumed if the third ALT remains ≥150 U/L (male) or 
≥100 U/L (female).  
• 
HBsAg-positive and HBeAg-positive at week 192. 
• 
HBsAg-positive, HBeAg-negative, and anti-HBe-negative at week 192   
 
6.14.3. Management after reinitiation of treatment  


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Participants who meet criteria for treatment reinitiation specified in section 6.14.2 will be 
restarted on Tenofovir DF 300mg daily. Tenofovir DF will be provided by the study until 
week 240. Monitoring of AST, ALT and HBV DNA levels will be done at 4, 8 and 12 
weeks after Tenofovir DF is restarted and then every 12 weeks. If bilirubin or INR is 
abnormal at the time of treatment reinitiation, it (they) should be monitored at 4, 8, and 
12 weeks after Tenofovir DF is restarted and then every 12 weeks until it (they) return(s) 
to normal. If, after treatment reinitiation, the participant meets criteria for non-response 
(section 6.9) or partial response (section 6.10), the drug therapy will be changed as 
outlined in those sections.  
 
7. Adverse events and toxicity management 
7.1. Criteria for permanent and premature discontinuation of treatment 
• 
Death 
• 
Grade IV toxicity (laboratory or clinical)  
• 
Hepatic decompensation defined by: 
o Total bilirubin ≥2.0 mg/dL and direct bilirubin ≥1.0 mg/dL 
o Any clinical decompensation 
 
7.2.a. Adverse effects of peginterferon alfa-2a 
Common side effects of peginterferon alfa-2a include influenza-like symptoms, 
particularly with the first few injections, fatigue, neuropsychiatric symptoms such as 
depression and reduction in white blood cell counts and platelet counts.  Hyper- or 
hypothyroidism has been noted to occur in up to 5% of participants receiving 
peginterferon alfa-2a. 
 
Some rare but potentially serious side effects include: 
• 
neuropsychiatric complications, which may include suicide, suicidal ideation, 
acute psychosis and severe depression 
• 
serious and severe bacterial infections; fatal infections have been reported during 
treatment with peginterferon alfa-2a 
• 
pancreatitis 
• 
interstitial pneumonitis, fatal cases have been reported with peginterferon alfa 2a 
use  
 
Other possible but uncommon adverse events associated with peginterferon alfa-2a 
include: 
• 
development or exacerbation of existing autoimmune disorders such as 
rheumatoid arthritis, systemic lupus erythematosus, idiopathic thrombocytopenic 
purpura, hemolytic anemia, type 1 diabetes, psoriasis, etc. 
• 
pulmonary disorders including dyspnea, pulmonary infiltrates, and sarcoidosis 
• 
exacerbations of inflammatory bowel disease  
• 
eye disorders, including decrease or loss of vision, retinal hemorrhages 
• 
hearing disorders, including loss of hearing and tinnitus 
• 
hypersensitivity reactions including severe skin reactions, in the spectrum of 
Stevens Johnson syndrome 
 
7.2.b. Peginterferon alfa-2a dose reductions 
Factors that will lead to a reduction in the dose of peginterferon alfa-2a include: 


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1. Disabling symptoms, which, in the opinion of the study physician, are related to 
peginterferon alfa-2a treatment and prevent the participant from performing 
his/her occupation or daily tasks. 
2. A rash consistent with allergic reaction or vasculitis. 
3. Reductions in the neutrophil count according to the guidelines in Appendix 2.  
4. A reduction in platelet count according to the guidelines in Appendix 2.  
5. Any adverse reaction, which, in the opinion of the study physician, places the 
participant at increased risk of a serious adverse effect. 
The dose of study medications may be decreased due to adverse events or laboratory 
abnormalities.  The weekly dose of peginterferon alfa-2a will be reduced in graduated 
steps as follows: 
• 
Level 1 decrease from 180 µg to 135 µg  
• 
Level 2 decrease from 135 µg to 90 µg 
• 
Level 3 decrease from 90 µg to 45µg  
 
For participants who require a downward dose adjustment for neutropenia or 
thrombocytopenia, laboratory values should be repeated, if practical, prior to the next 
dose of peginterferon alfa-2a to confirm the result and dictate the course of action.  
Participants who remain with a neutrophil count below 500/mm3 (but above 250/mm3) or 
a platelet count below 50,000/mm3 (but above 25,000/mm3) should receive stepwise 
dose reductions until levels of neutrophils and platelets are ≥ 500/mm3 or 50,000/mm3, 
respectively, or until a dose of 45 µg of peginterferon alfa-2a is reached.  Participants 
who have a neutrophil count below 250/mm3 or a platelet count below 25,000/mm3 
should have their peginterferon alfa-2a dose held.  Peginterferon alfa-2a may be 
resumed at the previous reduced dose when the neutrophil count has been above 
500/mm3 or platelet count above 50,000/mm3 on 2 occasions at least 1 week apart.  
 
7.2.c. Guidelines for subsequent peginterferon alfa-2a dose adjustments 
Once a participant’s dose has been decreased for laboratory abnormalities or adverse 
events, the study physician may attempt to increase the dose back to or toward the 
previous stable level only if the following conditions are satisfied: 
1. 
The event or circumstance responsible for the dosage adjustment has resolved 
or improved; 
2. 
The participant has been at the lower dose for ≤ 4 consecutive doses; 
3. 
The participant had ≤ 6 total doses administered at the lower level during the 
entirety of the treatment period.  
 
If four or more consecutive doses of peginterferon alfa-2a are held or otherwise not 
administered (i.e., the participant has not received test medication for more than 28 
days), the participant will be considered intolerant of the test medication or non-
compliant, whichever is more appropriate to the clinical situation.  In such cases, the 
study physician will discontinue peginterferon alfa-2a but tenofovir DF treatment will 
continue. 
 
Every attempt will be made to keep those participants randomized to treatment with 
peginterferon alfa-2a on therapy by dose reduction.  The use of hematological growth 
factors during the study will not be allowed. 
 
7.2.d. Screening and management for depression 


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The CES-D will be used, along with the study physician’s judgment, to screen 
participants for depression at the screening visit (8 weeks prior to randomization) and to 
monitor for onset or worsening of symptoms during the treatment. 
 
Screening Visit (8 weeks prior to randomization): If the participant has a CES-D score 
>15 at the screening visit (8 weeks prior to randomization), clearance from a mental 
health provider may be considered at the discretion of the study physician.  In addition to 
clarifying possible psychiatric disorders, the mental health provider may advise on the 
need for adjuvant medical or counseling therapy and suitability for enrollment. 
 
During treatment: Potential mood disturbance/medication intolerance will be assessed at 
each visit by study personnel.  The CES-D will be administered every 12 weeks for 48 
weeks.  If the participant has a score >15, the study physician will determine whether 
referral to a mental health provider is indicated. If the participant has a score of at least 
27, the study physician will refer to a mental health provider for evaluation and 
management. Any participant who develops recurrent suicidal ideation, a suicide plan 
and/ or makes a suicide attempt should have peginterferon alfa-2a immediately 
discontinued and be referred to a mental health provider for further management. 
 
Suggested guidelines for peginterferon alfa-2a dose reduction: 
• 
Unpleasant and/or disabling side effects might prompt dose reduction, but this is 
not required. 
• 
A CES-D score of 16-26 might prompt further consideration of dose reduction, 
but is not a requirement for dose reduction. 
• 
A score of at least 27 should prompt attention from the PI and dose reduction or 
discontinuation be considered. 
 
If the management of the depression is not successful after eight weeks or if the 
participant develops suicidal or homicidal ideation, the peginterferon alfa-2a will be 
stopped but tenofovir DF continued until the end of the treatment period.  The participant 
will be referred to a mental health provider.  
 
7.3.a. Adverse effects of tenofovir DF 
All nucleoside and nucleotide analogues carry a warning about the risk of lactic acidosis 
and severe hepatomegaly and steatosis because of the possibility of mitochondrial 
injury.  
 
Tenofovir DF has been associated with instances of lactic acidosis, but only in 
participants receiving other medications that have been associated with this 
complication, such as didanosine, stavudine and zidovudine.  It is not clear whether 
tenofovir DF when used by itself or in combination with peginterferon alfa-2a, is 
associated with mitochondrial toxicity either to the liver (lactic acidosis, acute fatty liver 
and hepatic failure), muscle (myositis), nerves (neuropathy) or pancreas (acute 
pancreatitis).  
 
In addition, all agents with activity against HBV replication carry a warning label about 
the risk of exacerbation of hepatitis after discontinuation of treatment. This issue is 
addressed by the protocol design and close follow-up of participants after stopping 
therapy (see section 6.6, 6.14.1, and Appendix 4). 
 
7.3.b. Tenofovir DF and renal function 


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Tenofovir DF is principally eliminated by the kidney. Renal impairment, including cases 
of acute renal failure and a Fanconi-like syndrome (proximal renal tubular dysfunction 
with severe hypophosphatemia), has been reported.  
 
Adverse Event Monitoring and Management Related to Elevated Serum Creatinine (Cr)  
Nephrotoxicity will be based upon serum creatinine results: 
• 
If Cr ≥0.5 mg/dL above baseline, repeat testing within 72 hrs will be performed 
and drug continued unless the study physician considers drug discontinuation 
necessary.  
• 
If Cr increases to ≥1.2 mg/dL and by ≥0.3 mg/dL from baseline, additional testing 
at the next scheduled visit should be considered (see Manual of Operations). 
If Cr ≥1.2 mg/dL and >0.5 mg/dl above baseline on two consecutive occasions, 
the study drugs will be discontinued and not restarted unless another, reversible 
cause of creatinine elevations is identified. If the study physician identifies an 
alternative cause for the increase in Cr, study drugs may be resumed at 
discretion of study physician if calculated Cr clearance is >30 ml/min with 
tenofovir DF dose adjustment. 
• 
Any study participant discontinued from the study will be recommended to 
commence anti-HBV therapy with an alternative HBV drug immediately (this drug 
will not be provided by the study). 
 
Tenofovir DF Dosing is Based Upon Creatinine Clearance (CrCL) 
Creatinine clearance will be calculated in all participants prior to initiating therapy and at 
each study visit to determine tenofovir DF dose.  
• 
Participants whose calculated creatinine clearance decreases to <50 ml/min 
should have this value confirmed within 72 hrs. If confirmed to be 30-50 ml/min, 
the dosing frequency for tenofovir DF should be adjusted from every 24 hours to 
every 48 hours until the calculated creatinine clearance returns to >50 ml/min. 
• 
Participants whose calculated creatinine clearance decreases to <30 ml/min, will 
be permanently discontinued from treatment and enter the follow-up phase.  
 
Adverse Event Monitoring and Management of Hypophosphatemia:  
If serum phosphate falls below 2.5 mg/dL and by at least 0.5 mg/dL from baseline, 
consider phosphate supplementation. Additional testing at the next scheduled visit 
should be considered (see Manual of Operations). 
• 
If the serum phosphate is <1.4 mg/dL, repeat testing within one week will be 
performed and supplementation provided as per manual of operations.  If serum 
phosphate is <1.4 mg/dL on repeat testing, urine and serum phosphate and 
creatinine will be determined to assess maximal phosphate tubular reabsorption 
and blood test should be performed to check potassium, calcium, bicarbonate, 
BUN and Cr.   
• 
Tenofovir DF dosing may be interrupted and aggressive supplementation with 
intravenous (if symptomatic) or oral (if no symptoms) phosphorus should be 
used. Repeat phosphate testing weekly until corrected to lower limit of normal 
range. If this intervention does not correct phosphate level in 2 weeks, Tenofovir 
DF should be permanently discontinued. 
• 
If serum phosphate is <1.0 mg/dL, participant will be asked to return immediately 
for further evaluation and treatment and Tenofovir DF dosing will be 
discontinued. 
 


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Any study participant discontinued from the study will be recommended to commence 
anti-HBV therapy with an alternative HBV drug immediately (this drug will not be 
provided by the study). 
 
7.3.c. Tenofovir DF and bone mineral density  
Decreases in bone mineral density have been observed in participants taking tenofovir 
DF for prolonged periods in the context of treatment for HIV infection.  These changes 
have been associated with significant increases in biochemical markers of bone 
metabolism, suggesting increased bone turnover.  Although the pathogenesis of these 
changes are not certain, they may be related to proximal renal tubulopathy, phosphate 
loss and a form of secondary hyperparathyroidism.   
 
Serum calcium, phosphate and creatinine levels will be monitored.  Serum vitamin D 
levels will be measured at baseline and supplements prescribed for the participants as 
clinically indicated.  Participants will have bone densitometry done prior to initiating 
therapy if clinically indicated (as standard of care).  If either osteopenia or osteoporosis 
is present on the bone densitometry done prior to initiation of treatment, the participant 
can be enrolled as long as he/she is concurrently treated for osteopenia or osteoporosis. 
Repeat bone densitometry may be performed if clinically indicated (as standard of care). 
 
7.3.d. Discontinuation of tenofovir DF for selected biochemical abnormalities 
Tenofovir DF will be permanently discontinued and the participant considered a 
treatment failure for Grade 3 hypophosphatemia (1.0-1.4 mg/dL) that does not correct 
within 2 weeks with phosphate supplements or Grade 4 hypophosphatemia (<1.0 mg/dL)  
or otherwise unexplained serum creatinine elevations by ≥1.2 mg/dL and >0.5 mg/dl 
above baseline on two consecutive occasions or calculated creatinine clearance <30 
ml/min that develop on therapy.  For lesser degrees of renal insufficiency not requiring 
discontinuation, the dose of tenofovir DF will be adjusted according to the 
manufacturer’s recommendation. 
 
7.4. Adverse events of emtricitabine and emtricitabine/tenofovir 
Emtricitabine alone or in combination with tenofovir coformulated as Truvada 
(emtricitabine 200 mg/tenofovir DF 300 mg) has not been approved for the treatment of 
chronic hepatitis B. Emtricitabine belongs to a class of anti-HIV drugs (nucleoside 
reverse transcriptase inhibitors). The most common side effects seen in ≥10% patients 
treated with emtricitabine in combination with other anti-HIV drugs are: headache, 
diarrhea, nausea, and elevation in creatine kinase. These side effects were generally 
mild to moderate in severity.  
 
Lactic acidosis (increase in lactic acid) is a very serious reaction, which is characterized 
by symptoms of nausea, vomiting, abdominal pain, general discomfort and tiredness that 
do not get better and also by severe hepatomegaly (enlargement of the liver) with 
steatosis (fatty deposits). Lactic acidosis, including fatal cases, has been reported with 
the use of nucleoside and nucleotide reverse transcriptase inhibitors. 
 
For people who are infected with HIV as well as hepatitis B, other possible risks of 
treatment with Truvada include making their hepatitis B worse. The potential risk relates 
to HBV flares induced by the discontinuation of Truvada and careful monitoring is 
required when the drug is stopped. There is no evidence of drug-drug interactions when 
emtricitabine and tenofovir are used in combination.  
 


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Truvada dosing is based upon CrCL 
Creatinine clearance will be calculated by the MDRD method in all participants prior to 
initiating therapy and at each study visit to determine Truvada dose.  
• Participants whose calculated creatinine clearance decreases to <50 ml/min 
should have this value confirmed within 72 hrs. If confirmed to be 30-50 ml/min, 
the dosing frequency for Truvada should be adjusted from every 24 hours to 
every 48 hours until the calculated creatinine clearance returns to >50 ml/min. 
• Participants whose calculated creatinine clearance decreases to <30 ml/min, will 
discontinue Truvada. Subsequent management will be at the discretion of the 
investigator, alternative antiviral therapy should be considered and the participant 
monitored until creatinine clearance returns to baseline or stabilizes.  
 
7.5. Pregnancy 
Female participants will be asked to practice effective birth control while they are taking 
antiviral agents in this study.  However, given the very long duration of therapy and the 
fact that many of the participants are expected to be females of child bearing potential, 
the following precautions will be taken: 
 
All female participants of child bearing potential will undergo a urine or serum pregnancy 
test prior to starting therapy and every visit during the peginterferon treatment phase.  If 
a participant is found to be pregnant, therapy will be adjusted as follows: 
• 
Peginterferon alfa-2a  will be permanently discontinued 
• 
Tenofovir DF can be continued throughout the pregnancy at the discretion of the 
study physician. 
• 
Emtricitabine/tenofovir (Truvada) can be continued throughout the pregnancy at 
the discretion of the study physician. 
 
The study will collect data on the outcomes of any pregnancies that occur in females 
who conceived while taking study medication.  
 
7.6. Adverse events – definition and management 
7.6.1. Definitions 
An adverse event (AE) is any adverse change from the participant’s baseline (pre-
treatment) condition, including intercurrent illness which occurs during the course of the 
trial, after the consent form has been signed, whether the event is considered related to 
treatment or not. 
 
The Common Terminology Criteria from the National Cancer Institute (NCI) of the 
National Institutes of Health will be used for grading severity of AEs.  For AEs not 
outlined in the Common Terminology Criteria, study specific definitions will be identified 
in the Manual of Operation (MOP).  
 
Serious Adverse Event: 
A serious adverse event is an untoward medical occurrence that results in any of the 
following: 
1. Death 
2. Is life threatening (risk of death at the time of the event) 
3. Requires in-patient hospitalization or prolongation of existing hospitalization 
4. Results in persistent or significant disability/incapacity 
5. Congenital abnormality or birth defect 
 


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Important medical events that do not result in one of the events listed above may be 
considered a serious adverse event when, based upon appropriate medical judgment, 
they may jeopardize the participant and may require medical or surgical intervention to 
prevent one of the outcomes listed above. 
 
A serious adverse event which is unexpected and is related will require expedited 
reporting to the DCC and the NIDDK and appropriate oversight committees or entities.  
 
Disease related outcomes, such as the following events, will not be considered to be 
serious adverse events: 
1. Development of HCC  
2. Hepatic decompensation 
 
Although pregnancy, overdose, cancer (excluding HCC), and potential drug induced liver 
injury (DILI) are not always serious by regulatory definition, these events must be 
handled as SAEs.  
 
Unexpected: 
An adverse event that is not listed in the Investigator’s Brochure (or package insert) or is 
not listed at the severity that has been observed. 
 
Suspected Adverse Reaction: 
Any adverse event for which there is a reasonable possibility that the drug caused the 
adverse event (i.e., there is evidence to suggest a causal relationship between the drug 
and the adverse event). 
 
SAE Reporting: 
This trial will be conducted under U.S. IND.  Therefore, the safety data required to meet 
IND regulatory requirements will be collected through adverse event reporting by the 
clinic investigators and will be provided by the Data Coordinating Center to the NIDDK 
for transmission to the FDA. 
 
A serious adverse event which is unexpected and is drug related (even remotely) will 
require expedited reporting to the drug manufacturer, the DCC and to local IRB/REBs 
(per local IRB/REB policy). 
 
Only serious and unexpected suspected adverse reactions with evidence of a causal 
relationship to the study and/or study drug will be reported to the FDA as an IND safety 
report according to 21 CFR 312.32.   
 
Unexpected fatal or life-threatening suspected adverse reactions must be reported to 
FDA no later than 7 calendar days after the sponsor’s initial receipt of the information. 
 
All other unexpected serious suspected adverse reactions must be reported to FDA no 
later than 15 calendar days after the sponsor’s initial receipt of the information. 
 
A summary of adverse events will be reported to the FDA as part of the IND annual 
report. 
 
7.6.2. Data collection procedures for adverse events 
Participants will be interviewed regarding medical conditions, medication changes, and 


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symptoms that have occurred at each study visit. An Adverse Event form will be 
completed if any adverse event is reported. If the Study Coordinator or Principal 
Investigator learns of any hospitalizations or other adverse events between study visits, 
an Adverse Event form will be completed. All adverse events and Serious Adverse 
Events from time of study entry (consent) up to the end of follow-up (week 240 or end of 
the study) will be reported to the DCC. 
 
A Serious Adverse Event form will be completed for all adverse events rated as serious. 
 
Participants will be followed for all ongoing unresolved adverse events until they are 
either resolved, or in the opinion of the Principal Investigator, the participant is medically 
stable. 
 
The investigator will assess the relationship of each adverse event to the use of study 
drug, based on available information, using guidelines outlined in the MOP.  
 
7.6.3. Reporting procedures 
All serious adverse events that are unexpected and related to study drug(s) will be 
reported to the DCC within 24 hours of knowledge of the event, via the Serious Adverse 
Event form. This reporting includes serious adverse events that occur from the time the 
participant has signed the clinical trial consent. 
 
The DCC will distribute the expedited report to the NIDDK, the appropriate oversight 
committees or entities, and clinical centers. Status reports on serious adverse events will 
be generated by the DCC and will include the relationship of the adverse event to trial 
medications, the severity of the event and if the event is resolved or ongoing.   
 
All deaths will be reported to the DCC within 24 hours of knowledge of the death via the 
Serious Adverse Event form. This reporting begins at the time the participant has signed 
the informed consent up to the last scheduled participant visit. The report will include the 
relationship of the death to trial medications. A Clinical Outcome form will also be 
completed and sent to DCC for distribution. Deaths will be reported immediately to the 
NIDDK, the appropriate oversight committees or entities, and the clinical centers. A 
death will be reported as an expedited report only if it is unexpected and drug related. A 
death must also be reported in accordance with local law and regulations. 
 
The HBRN will comply with Genentech/Roche SAE reporting requirements (see Manual 
of Operations). 
 
8. Statistical considerations 
8.1. Statistical analysis 
Summary statistics will be generated to describe the study sample at baseline.  
Descriptive statistics, including measures of central tendency (e.g. means, medians) and 
estimates of spread (e.g., standard deviations, quartiles) will be used for continuous 
variables such as age and baseline HBV DNA and HBsAg levels.  Frequency 
distributions will be used for categorical variables such as HBV genotype and HBeAg 
status.  Ninety-five percent confidence intervals will be calculated for all point estimates 
of continuous data.  Graphical displays (e.g. histograms, box plots) will also be used to 
describe the data. The baseline demographic information and viral characteristics will be 
compared between the two treatment arms using the chi-square test for association or 
exact tests for differences in proportions for categorical variables or using a test of trend 


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in ordinal data. Continuous variables may be transformed, where appropriate, to meet 
the assumptions of parametric tests.  The Student’s t-test or a non-parametric 
alternative, the Wilcoxon rank-sum test, will be used to determine differences in the 
distribution of continuous data between the two treatment arms.  
 
Primary analyses will be performed using all enrolled participants (intention-to-treat 
analysis). Participants will be considered enrolled in the study upon being randomized to 
one of the two treatment arms.   
For all analyses, a p-value of less than 0.05 will be used to indicate statistical 
significance. 
 
8.1.1. Analysis of primary endpoint 
The primary endpoint is loss of HBsAg at week 240.  The cumulative proportion of 
HBsAg loss at the designated time-point will be estimated using the product-limit 
(Kaplan-Meier) estimate. HBsAg loss between two treatment groups will be compared 
using a Wald-type two-sided two-sample proportion test (chi-square test).   
 
8.1.2. Analysis of secondary endpoints 
Analysis of secondary endpoint listed in 2.2.1a: To compare the cumulative proportion 
HBsAg loss over time during and after treatment  
Cumulative proportion of HBsAg loss over time will be calculated using the product limit 
(Kaplan-Meier) method. HBsAg loss between two treatment groups will be compared 
using a two-sided two-sample stratified log-rank test.  We will also describe the 
treatment effects in terms of hazard rates of HBsAg-loss and corresponding 95% 
confidence intervals. To take into account the stratification at randomization, we will use 
stratified Cox proportional hazard models. Comparison of hazard rates of HBsAg loss 
across two treatment groups adjusting for other baseline demographic, virological and 
clinical characteristics such as age, race, genotype, HBeAg status, initial HBV DNA 
level, and baseline histology will be performed using Cox proportional hazard regression. 
The results will be presented as incidence rate ratios of HBsAg loss and 95% confidence 
intervals. 
 
8.1.2.1. Analyses of other secondary endpoints  
Secondary endpoints for this clinical trial are listed in sections 2.2.1 – 2.2.9. These 
endpoints could be grouped into several different classes. The first group of endpoints 
we will deal with are binary endpoints characterized by the occurrence of some event by 
a fixed time point. These events include HBeAg loss, HBeAg seroconversion, HBsAg 
seroconversion, normalization of ALT, ALT ≤1.25 X ULN, HBV DNA <1000 IU/mL, HBV 
DNA <20 IU/mL, absence of detectable antiviral drug-resistance HBV mutations, 
treatment discontinuation, and treatment failure. Analysis will be conducted separately 
for these events at the designated time points listed in sections 2.2.1-2.2.9 
 
Proportion of such an event (e.g. proportion of HBeAg loss) between two treatment 
groups will be summarized using 95% confidence intervals and will be presented 
graphically by using bar charts. The rate of occurrence of an event between two 
treatment groups will be compared using a two-sided two-sample proportion test (chi-
square test or Fisher’s exact test as appropriate).  We will also describe the treatment 
effects using relative risk of the event and corresponding 95% confidence interval. In 
order to take into account the stratification at randomization, we will use Mantel-
Haenszel chi-square test. Comparison of rates of an event across two treatment groups 
adjusting for other baseline demographic, virological and clinical characteristics such as 


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age, race, genotype, HBeAg status, initial HBV DNA level, and baseline histology will be 
performed using multivariable log-linear (Poisson) regression, with HBsAg loss (Yes/No) 
as the outcome. The results will be presented as relative risks of the event and their 95% 
confidence intervals.  
 
Time to such events may also be of interest (e.g. cumulative HBeAg loss, time to 
treatment failure). For time-to event analysis, Kaplan-Meier curves will be used to plot 
the cumulative proportion of events over time by treatment groups. The cumulative 
proportions will then be compared using two-sided stratified log-rank test. The treatment 
effect will be described using hazard rate of the event and corresponding 95% 
confidence interval. In order to take into account the stratification at randomization, we 
will use stratified Cox proportional hazard models. Comparison of hazard rates of an 
event across two treatment groups adjusting for other baseline demographic, virological 
and clinical characteristics such as age, race, genotype, HBeAg status, initial HBV DNA 
level, and baseline histology will be performed using Cox proportional hazard regression. 
The results will be presented using hazard rates and 95% confidence intervals. 
 
The second group of endpoints is continuous variables such as changes in ALT, HBV 
DNA levels from baseline at designated treatment or follow-up time points. Descriptive 
statistics, including measures of central tendency (e.g. means, medians) and estimates 
of spread (e.g., standard deviations, quartiles) will be used to characterize such 
changes. Student’s t-test or a non-parametric alternative, the Wilcoxon rank-sum test, 
will be used to determine differences in the distribution of these changes between the 
two treatment arms. Multiple regression analyses will be conducted to assess the 
association between baseline characteristics and these changes. Spearman or Pearson 
correlation coefficients will be used to measure the strength and direction of the 
association between such changes and other participant characteristics. Scatter plots 
will be used to display the association between continuous variables. 
 
The third group of variables consists of variables that are measured over time 
(longitudinal data) such as quantitative HBV DNA levels.  For graphical representation 
over time, we will use spaghetti plots of original data (e.g. HBV DNA levels) and 
summarize the pattern of data across subgroups (e.g. genotype, treatment groups) over 
time by using means (for continuous outcome) or proportions (for binary outcomes). To 
determine the significance of change in continuous outcome over time across treatment 
group adjusting for other baseline and longitudinal participant characteristics, we will use 
mixed models if the data are normally distributed or generalized estimating equations 
(GEE) if deviation from normality is evidenced. These approaches simultaneously model 
the regression of the response variable on the independent variables and account for the 
correlated nature of the responses.  Analyses using conventional regression methods 
could provide erroneous variance estimates and loss of statistical efficiency because of 
the conventional assumption that each response is statistically independent.  As a result, 
invalid inferences could be made if the conventional approach were applied to these 
longitudinal data.  A similar approach of analysis will be adopted (generalized linear 
mixed model or GEE) for longitudinal binary or count outcomes over time. 
 
The results will be summarized using rate of change/odds ratio/relative risk over time 
and the corresponding confidence intervals. Interaction between treatment and 
participant characteristics will be investigated to assess the differential effect of 
treatments across subgroups of participants (e.g. genotypes).  
 


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Secondary endpoints that are defined within a specific subgroup will be analyzed only for 
participants in that subgroup.  For example, sustained off treatment (36 and 48 weeks 
after end of treatment) responses will be assessed only among those whose treatment 
was discontinued at week 192. 
 
 
8.2. Missing data 
Primary analyses will be performed using all enrolled participants (intention-to-treat 
analysis). For the primary analysis, the proportion of patients with HBsAg loss at the end 
of follow-up (week 240) will be estimated using the product limit (Kaplan-Meier) method 
which includes drop outs for as long as they are followed. Since our sample size 
estimation accounts for participants lost to follow up for various reasons, and due to 
randomization, the rate of missing is expected to be similar in the two treatment groups, 
we will also conduct the analysis of primary endpoint on the available cases. For this 
analysis, we will describe the treatment effects in terms of relative risks and 95% 
confidence intervals. In order to take into account the stratification at the randomization, 
we will use Mantel-Haenszel chi-square test.  Comparison of rates of HBsAg loss across 
two treatment groups adjusting for other baseline demographic, virological and clinical 
characteristics such as age, race, genotype, HBeAg status, initial HBV DNA level, and 
baseline histology will be performed using multivariable log-linear (Poisson) regression, 
with HBsAg loss (Yes/No) as the outcome.  The results will be presented as relative 
risks of HBsAg loss and their 95% confidence intervals. 
 
In general, the procedure of missing outcome data will be handled as follows in 
statistical analyses. First, we will explore the pattern of missing data by comparing 
characteristics of participants with available data to those with missing data. For data 
missing completely at random (does not depend on observed outcome; MCAR) standard 
analytical techniques described earlier would produce unbiased results when the 
analysis is performed on the complete data. For the time-to-event data analyses, the 
analytical methods such as Kaplan-Meier method, log-rank test, and Cox proportional 
hazard model automatically accounts for MCAR drop-outs. However, in other cases, we 
will assume that the dropout depends on observed outcome and/or covariates (missing 
at random, MAR). For such scenarios, likelihood-based methods such as mixed models, 
generalized linear mixed models and logistic regression will provide unbiased inference. 
For GEE, we will draw inference using inverse-probability-weighting approach, with 
models fitted using the reciprocal of the estimated probability of missing as weights. The 
probability of missing will be estimated using logistic regression.    
 
It is unlikely that the probability of missing will depend on unobserved outcome and/or 
covariates (missing not at random, MNAR). However selection models such as MNAR 
Dale model and Diggle-Kenward model (23) can be used in such cases. These models 
often require strong assumptions on the dropout mechanism, which are primarily 
unverifiable based on the observed data. We will conduct sensitivity analyses to 
investigate the sensitivity of our conclusion to possible violation of such assumptions by 
fitting models under MCAR, MAR and MNAR assumptions and compare the model fits 
using log-likelihoods. 
 
8.3. Safety analysis 
8.3.1. Adverse events  
Summaries of adverse events (number adverse events, number and percentage of 
participants with adverse events, rates per person-years) will be provided by treatment 


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group. Events will be summarized based on the date of onset for the event. A treatment 
emergent adverse event will be defined as an adverse event that begins on or after the 
date of first dose of study drug. Events that occur prior to the first dose of study 
medication or after the last dose of study medication will be summarized separately. 
Summaries of the following are planned:  
• 
all adverse events recorded between screening and first dose of study 
medication,  
• 
all treatment emergent adverse events,  
• 
all emergent and related adverse events,  
• 
all treatment emergent renal adverse events, 
• 
all treatment emergent and related renal adverse events 
• 
combined Grade 2, 3 and 4 treatment emergent adverse events,  
• 
combined Grade 2, 3 and 4 related treatment and emergent adverse events,  
• 
combined Grade 3 and 4 treatment emergent adverse events,  
• 
combined Grade 3 and 4 related treatment and emergent adverse events,  
• 
all adverse events that caused permanent discontinuation of study drug,  
• 
all adverse events that caused temporary interruption of study drug,  
• 
all serious adverse events, and  
• 
all serious and related adverse events.  
 
In addition quarterly safety analysis will be reported to DSMB. 
 
8.3.2. Laboratory abnormalities 
Laboratory results will be presented as both actual value as well as a function of normal 
range. Selected laboratory data (using conventional units) will be summarized by the 
change from baseline in laboratory test. If baseline data are missing, then any graded 
abnormality is considered treatment emergent.  
 
8.3. Sample size and power 
The sample size for this study was determined based on the primary endpoint of HBsAg-
loss at 48 weeks after treatment has been stopped. There are no data available on 
HBsAg loss for long-term treatment with tenofovir DF or tenofovir DF and peginterferon 
combination therapy. We anticipate that after 192 weeks of treatment and 48 weeks of 
follow-up post-treatment 5% of the participants in the tenofovir DF alone group will 
achieve HBsAg loss compared to 15% participants in the tenofovir DF and peginterferon 
combination therapy group. The clinical trial would require 141 participants per arm (282 
participants in total) to detect this expected difference with 80% power at 5% level of 
significance using a two-sided test of equality between two proportions (chi-square test). 
However, for this long-term treatment trial, it is expected that approximately 25% of the 
participants will be lost to follow-up and hence the study will recruit a total of 376 
participants (randomized 1:1 to two treatment arms, 188 per arm) to account for the 
missing participants.  
 
9. Data and safety monitoring board 
Data and safety will be monitored by the NIDDK in conjunction with an NIDDK-appointed 
Data and Safety Monitoring Board (DSMB).  This board serves in a consultative capacity 
to inform the NIDDK decisions regarding conduct of the study.  The description of DSMB 
activities is included in the DSMB Charter. 
 


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9.1 Data and safety monitoring plan 
This phase III randomized trial aims to compare the long-term efficacy of initial treatment 
with combination therapy with peginterferon plus tenofovir DF versus tenofovir DF 
monotherapy in the treatment of chronic hepatitis B. The individual drugs (peginterferon 
and tenofovir DF) are FDA-approved and have been well-studied.  The risks to 
participants are outlined in sections 5.2.3 and 5.3.3 in the accompanied protocol.  
Section 7 of the protocol defines the toxicities associated with these drugs and outlines 
dose adjustment and discontinuation guidelines due to toxicity.  
 
Emtricitabine/tenofovir DF coformulated as a single tablet Truvada is approved for HIV 
but not for HBV treatment. Emtricitabine/tenofovir DF will be offered to patients who 
have primary nonresponse, partial virologic response or confirmed virologic 
breakthrough. Adverse events and dose adjustment guidelines are described in section 
7.4.  
 
The data and safety monitoring plan (DSMP) for this study focuses on close monitoring 
by the principal investigators (PI) and prompt reporting of excessive adverse events and 
all serious adverse events to the DCC and the appropriate oversight committees or 
entities such as the NIDDK, the Data and Safety Monitoring Board (DSMB) and to the 
participating centers’ IRB/REBs. 
 
The Data Coordinating Center (DCC) will monitor clinical center performance (e.g., 
recruitment, retention, data completeness, timeliness of data collection and submission) 
and protocol compliance. These reports, with summaries of adverse event data, will be 
provided to the DSMB for their quarterly reports and biannual calls or meetings, and to 
the Steering Committee at its annual meeting. DSMB reports will include both open and 
closed session reports, with only the latter including information by treatment arm. 
 
The DCC will work with the Safety Officer and the Steering Committee to maintain a 
cumulative summary of adverse events (overall and stratified by serious/non-serious 
status) that will be forwarded to the DSMB every three months. Safety reports will also 
be sent to the Principal Investigators and the NIDDK Project Officers. The Project 
Coordinator will be responsible for distributing these reports and assuring that all parties 
obtain copies of these reports. 
 
The frequency of data review for this study differs according to the type of data and can 
be summarized in the following table: 
 
Data type 
Frequency of review 
Recruitment 
Retention 
Protocol adherence(e.g., meeting 
inclusion/exclusion criteria, treatment 
compliance) 
Pregnancy and outcomes in female 
participants 
Quarterly reports for NIDDK and the 
appropriate oversight committees 
Adverse events and Serious Adverse Events 
(SAE) that do not meet expedited reporting 
criteria 
Quarterly reports for NIDDK and the 
appropriate oversight committees 
Serious Adverse Events that meet expedited 
reporting criteria* 
As they occur for NIDDK, DSMB, 
appropriate industry partner(s), and 


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cumulative reports quarterly 
Laboratory data  
Yearly for the DSMB 
 
The definition of adverse and serious adverse events is provided in section 7.6.1 of this 
protocol along with the reporting procedures in the MOP.  
 
Stopping rules during the treatment phase (up to Week 192) 
No interim analysis for efficacy is planned for this clinical trial, since the primary endpoint 
is expected to occur very rarely during the treatment period.  As mentioned above, 
adverse event reporting will be quarterly throughout the study. Additional analyses will 
be performed at the recommendation of the DSMB if there are any concerns raised by 
adverse events or serious adverse events reported.  The following study-wide stopping 
rules have been agreed upon by the clinical investigators for this interim analysis. The 
study will be stopped if at least one of the following occurs: 
1. If the incidence of renal toxicity (defined as a persistent increase in serum 
creatinine >1.0 mg/dL above baseline on two successive visits 4 weeks apart or 
persistent grade 3 or grade 4 hypophosphatemia (requiring TDF discontinuation) 
exceeds 10% in either of the two study arms. 
2. If the incidence of peripheral neuropathy (documented by EMG) exceeds 10%. 
3. If the incidence of grade IV toxicity exceeds 10% in either of the two study arms. 
 
Stopping rules during treatment discontinuation phase (Weeks 192 to 240) 
The following has been agreed upon by the clinical investigators 
1. If more than 1 participant develops clinical decompensation, no further 
participants will undergo treatment withdrawal until the formal review by 
investigators and the DSMB 
2. Resumption of treatment withdrawal may occur if the DSMB and investigators 
determine the safety measures are adequate AND that the benefits of continued 
study of treatment withdrawal outweighs the risks 
 
9.2 Participant Confidentiality 
The central database of the study is on a server at the Epidemiology Data Center (EDC) 
at the University of Pittsburgh secured behind locked doors and an alarm with password 
access provided only to authorized personnel.  Backups are performed daily to guard 
against data loss due to an equipment or power failure.  Scheduled backups and 
archives at the EDC protect central and local information from hard disk failures.  Tape 
backup volumes and CD-ROM copies of critical project files are located in a secured off-
site storage area to prevent data loss due to catastrophic events.  Routine virus 
detection is also enforced for all EDC computers involved in the study.  All critical 
information regarding database transactions is logged and stored in journal files.  In the 
event of accidental corruption of the project database, a previous database state may be 
restored from backup volumes or journal files.  All servers used for this project are 
connected to uninterrupted power supplies to protect equipment against electrical surges 
and outages.  A secured, raised-floor computer room in an area with a burglar alarm 
houses all project server equipment.  
 
Subject confidentiality is preserved by encoding subject names into alphanumeric IDs at 
the clinical centers.  Data sent to the DCC are identified by alphanumeric ID only. No 
reports of this study will use names or other identifying information such as social 
security numbers or addresses.  Data, with alphanumeric ID only, will be stored at the 
DCC indefinitely.  In addition, following the completion of the study, data and information 


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with alphanumeric ID only, will be submitted to the NIDDK repository by a suitable date 
agreed upon by NIDDK and the steering committee.   


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References 
 
1. Shepard CW, Simard EP, Finelli L, Fiore AE, Bell BP. Hepatitis B virus infection: 
epidemiology and vaccination. Epidemiol Rev 2006;28:112-25 Epub 2006 Jun 5. 
2. Lok AS, McMahon BJ. Chronic hepatitis B. Hepatology 2007;45(2):507-39. 
3. Hoofnagle JH, Doo E, Liang TJ, Fleischer R, Lok AS. Management of hepatitis B: 
summary of a clinical research workshop. Hepatology 2007;45(4):1056-75. 
4. Yim HJ, Lok AS. Natural history of chronic hepatitis B virus infection: what we knew 
in 1981 and what we know in 2005. Hepatology 2006;43(2 Suppl 1):S173-81. 
5. Hui CK, Leung N, Yuen ST, et al. Natural history and disease progression in Chinese 
chronic hepatitis B patients in immune-tolerant phase. Hepatology 2007;46(2):395-401. 
6. Manno M, Cammà C, Schepis F, et al. Natural history of chronic HBV carriers in 
northern Italy: morbidity and mortality after 30 years. Gastroenterology 2004;127(3):756-
63. 
7. EASL Clinical Pracice Guidelines: Management of chronic hepatitis B. J Hepatol 
2009;50:in press. 
8. Liaw YF, Leung N, Kao JH, et al. Asian-Pacific consensus statement on the 
management of chronic hepatitis B: a 2008 update. Hepatol Int 2008;2(3):263-83. 
9. Belongia E, Costa J, Gareen I, et al. NIH consensus development statement on 
management of hepatitis B. NIH Consens State Sci Statements 2008;25(2):1-29. 
10. Perrillo R. Benefits and risks of interferon therapy for hepatitis B. Hepatology 
2009;49(Suppl 5):S103-11. 
11. Dienstag J. Benefits and risks of nucleoside analog therapy for hepatitis B. 
Hepatology 2009;49(Suppl 5):S112-21. 
12. Lau GK, Piratvisuth T, Luo KX, et al. Peginterferon Alfa-2a, lamivudine, and the 
combination for HBeAg-positive chronic hepatitis B. N Engl J Med 2005;352(26):2682-
95. 
13. Buster EH, Flink HJ, Cakaloglu Y, et al. Sustained HBeAg and HBsAg loss after 
long-term follow-up of HBeAg-positive patients treated with peginterferon alpha-2b. 
Gastroenterology 2008;135(2):459-67. 
14. Chang TT, Gish RG, de Man R, et al. A comparison of entecavir and lamivudine for 
HBeAg-positive chronic hepatitis B. N Engl J Med 2006;354(10):1001-10. 
15. Lai CL, Gane E, Liaw YF, et al. Telbivudine versus lamivudine in patients with 
chronic hepatitis B. N Engl J Med 2007;357(25):2576-88. 
16. Heathcote E, Gane E, DeMan R, et al. A Randomized, Double-Blind, Comparison of 
Tenofovir DF (TDF) Versus Adefovir Dipivoxil (ADV) For the Treatment of HBeAg 
Positive Chronic Hepatitis B (CHB): Study GS-US-174-0103. Hepatology 2007;46(4 
(Suppl)):LB6. 
17. Marcellin P, Buti M, Krastev Z, et al. Two Year Tenofovir Disoproxil Fumarate (TDF) 
Treatment and Adefovir Dipivoxil (ADV) Switch Data in HBeAg-Negative Patients with 
Chronic Hepatitis B (Study 102). Hepatology 2008;48(4 (suppl)):370A. 
18. Hadziyannis SJ, Tassopoulos NC, Heathcote EJ, et al. Long-term therapy with 
adefovir dipivoxil for HBeAg-negative chronic hepatitis B for up to 5 years. 
Gastroenterology 2006;131(6):1743-51. 
19. Marcellin P, Lau GK, Bonino F, et al. Peginterferon alfa-2a alone, lamivudine alone, 
and the two in combination in patients with HBeAg-negative chronic hepatitis B. N Engl J 
Med 2004;351(12):1206-17. 
20. Lau D, Everhart J, Kleiner D, et al. Long-term follow-up of patients with chronic 
hepatitis B treated with interferon alfa. Gastroenterology 1997;113:1660-7. 
21. Terrault N. Benefits and risks of combination therapy for hepatitis B. Hepatology 
2009;49((5 Suppl)):S122-8. 


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22. Gupta SK. Tenofovir-associated Fanconi syndrome: review of the FDA adverse 
event reporting system. AIDS Patient Care STDS 2008;22(2):99-103. 
23. Molenberghs G, Kenward M. Missing Data in Clinical Studies. London: Wiley. 
 


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Appendix 1: Dosing of peginterferon if missed doses 
 
Dose delayed 1 or 2 days: administer on usual dosing day of the week (e.g., if Monday is 
the usual dosing day and the dose is delayed until Wednesday, the next dose may be 
administered as usual on Monday). 
Dose delayed 3-5 days:  administer subsequent doses every 5th or 6th day until the 
participant is back to his or her original schedule (e.g., if Monday is the usual dosing day 
and the dose is delayed until Saturday, the next dose should be administered on 
Thursday, the following dose on Tuesday, then the dose after that as usual on Monday). 
Dose delayed 6 days:  hold the dose for that week then continue on the usual schedule 
the following week (e.g., if Monday is the usual dosing day but the participant is not 
ready to be dosed until the following Sunday, the dose is considered to have been held 
and the next injection should be for the following weeks; dose on Monday). 
Dose delayed 7 or more days: the investigator may reintroduce study drug at any time 
and, if necessary, dose the participant every 5th or 6th day until the participant resumes 
weekly dosing on their usual scheduled day. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


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Appendix 2:  Peginterferon alfa-2a dose adjustment guidelines 
Specific dose adjustment guidelines for peginterferon alfa-2a are provided in the tables 
below for neutropenia, and thrombocytopenia. For other adverse effects considered to 
be possibly related to peginterferon, including laboratory abnormalities, adverse events, 
and vital signs changes, study physicians should utilize the table below labeled “General 
Dose Reduction Guidelines.” When practicable, abnormal laboratory results should be 
confirmed as soon as possible following notification of the study physician. If 
appropriate, downward adjustments in one level reductions should be considered. The 
lowest dose of peginterferon alfa 2a that should be administered is 45 µg weekly. It 
should be kept in mind that whereas these guidelines should be generally followed to 
promote consistency across centers, other responses by a study physicians may be 
more appropriate in some circumstances. 
 
a. General dose reduction guidelines 
 
For Peginterferon alfa-2a, 1 dose reduction = 135 µg; 2 dose = 90 µg; 3 dose = 45 µg 
Number of Dose Reduction Levels 
Mild 
Moderate 
Limited 
Moderate 
Persistent 
Severe 
Limited 
Severe 
Persistent 
Life- 
Threatening 
0 
0 
0-1 
0-1 
1-3 
Stop drug 
 
b. Dose adjustments for low absolute neutrophil and platelet counts for 
participants who enter the trial with ANC > 1500 and platelet count > 90,000. 
Parameter 
Downward Dose Adjustment or Delay in Dosing 
ANC (cells/mm3) 
 
≥500 
No change 
250-499 
1 step initially; potentially up to 3 steps 
<250 
Stop drug 
Platelet Count 
(cells/mm3) 
 
>50,000  
No change 
25,000-50,000 
1 step initially; potentially up to 3 steps 
<25,000 
Stop drug 


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Appendix 3:  Time and event chart for screening, baseline, and up to week 192 while on treatment 
Event 
Screen 
(weeks) 
Weeks on Treatment 
Weeks of Treatment 
-8 
01 
4 
8 
12 
24 
36 
48 
60 
72 
84 
96 
108 
120 
132 
144 
156 
168 
180 
192 
Informed consent 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Medical history 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Physical exam 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
X 
Limited clinical evaluation 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
Assessment of AE, concomitant  
meds, adherence 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Symptom questionnaire 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Questionnaires (QOL) 
 
X 
 
 
 
 
 
X 
 
 
 
X 
 
 
 
X 
 
 
 
X 
Depression  assessment 
X 
X 
 
 
X 
X 
X 
X 
 
 
 
X 
 
 
 
 
 
 
 
X 
Health behavior 
 
X 
 
 
 
 
 
X 
 
 
 
X 
 
 
 
X 
 
 
 
X 
Fatigue questionnaire 
 
X 
 
 
 
X 
 
 
 
 
 
X 
 
 
 
 
 
 
 
X 
CBC with platelet (differential up to 
week 36) 
X 
X 
X 
X 
X 
X 
X 
X 
 
 
 
X 
 
 
 
X 
 
 
Xa 
X 
Hepatic panel (AST, ALT, bilirubin)2 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Other liver tests (albumin, total 
protein, ALKP) 
X 
X 
 
 
 
 
 
X 
 
 
 
X 
 
 
 
X 
 
 
Xa 
X 
Renal Panel  (Creatinine, calculated 
CrCl, BUN, Ca, PO4) 
X 
X 
 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Vitamin D 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Other Chemistries (triglycerides, 
glucose) 
X 
 
 
 
 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
TSH3 
X 
 
 
 
X 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Urinalysis 
X 
X 
 
 
 
 
 
X 
 
 
 
X 
 
 
 
X 
 
 
 
X 
Urine creatinine, urine PO4 
4 
 
X 
 
 
 
 
 
 
 
 
 
X 
 
 
 
 
 
 
 
X 
Pregnancy test5 
X 
X 
X 
X 
X 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
PT/INR 
X 
X 
 
 
 
 
 
X 
 
 
 
X 
 
 
 
X 
 
 
Xa 
X 
AFP 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Anti-HCV6 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Anti-HDV6 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Anti-HIV7 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
X 
Serum/plasma banking8 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
HBeAg 
X 
X 
 
 
 
 
 
X 
 
 
 
X 
 
 
 
X 
 
 
X 
X 
anti-HBe9 
X 
X 
 
 
 
 
 
X 
 
 
 
X 
 
 
 
X 
 
 
X 
X 
anti-HBs9 
X 
X 
 
 
 
 
 
X 
 
 
 
X 
 
 
 
X 
 
 
 
X 
HBsAg 
X 
 
 
 
 
 
 
X 
 
 
 
X 
 
 
 
X 
 
 
X 
X 
HBsAg quant  
 
X 
 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
HBeAg quant 
 
X 
 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Quant HBV DNA 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
HBV genotype and subtype (if not 
done in cohort study)10 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Serum uric acid 
X 
 
 
 
 
 
 
X 
 
 
 
X 
 
 
 
X 
 
 
 
X 
HBV precore/BCP 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
X 


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Version 7.0 October 23, 2018 
 
Antiviral resistance testing11 
X 
 
 
 
 
 
 
X 
 
 
 
X 
 
 
 
X 
 
 
 
X 
DNA banking12 
 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
DEXA scan (if participant has risk 
factors)13 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Ultrasound exam/Imaging14 
X 
 
 
 
 
 
 
X 
 
 
 
X 
 
 
 
X 
 
 
 
X 
Liver Biopsy 
X15 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Eye examination (if participant has 
risk factors)16 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Anti-HBc IgM 
X17 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Fibroscan (if available) 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
X18 
X18 
            1 Day 0 is the Baseline visit, date of randomization, and start of study drug. 
       a Platelets, albumin, and INR required 
            2 If total bilirubin elevated, obtain direct bilirubin at next blood draw. 
3 If abnormal, continue to follow until normalizes. 
4 Fasting urine tests at weeks 96 and 192. 
5 In females of childbearing potential during the peginterferon treatment phase. 
6 Anti-HCV and anti-HDV if results within 144 weeks of screening visit are available need not be repeated, these results may have been entered into cohort study database.  
7 Anti-HIV must be tested at screening (within 8 weeks prior to randomization) and again at week 196. 
824mL of serum and 8mL of plasma at screening (within 8 weeks prior to randomization), week 0, 48, 96 144 and 192, 8mL tube of serum and 8mL of plasma at other time points. 
For patients not already enrolled in cohort, an additional 8 mL serum and 8 mL plasma should be collected at baseline visit (Day 0) for future research.  
9 Anti-HBe/Anti-HBs to be done at next visit if HBeAg/HBsAg becomes negative.  
10 The genotype result from the CDC should be used to randomize a participant; however, a result from a local lab may be used if the result from the CDC is not yet available. If a 
blood sample for CDC genotype testing was not collected as part of the Cohort Study, a sample should be obtained at the screening visit for the trial.  
11 Baseline and every 48 weeks in patients with detectable HBV DNA also performed if criteria for non-response, partial response or virologic breakthrough met. 
12 DNA – 5 mL whole blood at any time during the trial if not collected previously.   
13 If clinically indicated. 
14 Participants with AFP>20 ng/mL must be further evaluated by imaging (CT or MRI) as clinically indicated to rule out HCC before entry into the study. Participants meeting 
AASLD criteria for HCC surveillance will have follow-up imaging as standard of care. 
15 Slides of biopsy performed within 144 weeks of treatment start date (randomization) must meet criteria for adequacy by local consortium pathologist to confirm Modified Ishak 
HAI ≥3 or Ishak fibrosis ≥1 or both and the slides must be available for subsequent central read.  
16 In participants with diabetes or hypertension and no eye examination within past 48 weeks (standard of care). 
17 In participants who were not documented to be HBsAg positive at least 24 weeks prior to the positive result during screening. 
18 Fibroscan (if available) no earlier than week 180 visit and no later than week 192 visit  
 
 
 
 
 
 
 
 
 
 
 


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Appendix 4:  Time and event chart after week 192 or treatment discontinuation * 
Weeks Post Treatment Discontinuation 
4 
8 
12 
165 
205 
24 
36 
48 
Study Week 
196 
200 
204 
208 
212 
216 
228 
240 
Medical history 
 
 
 
 
 
 
 
X 
Physical exam 
 
 
 
 
 
 
 
X 
Clinical evaluation (limited) 
X 
X 
X 
X 
X 
X 
X 
 
Assessment of AE, concomitant meds 
X 
X 
X 
X 
X 
X 
X 
X 
Questionnaires (QOL, Depression assessment, Fatigue questionnaire, and Health behavior)  
 
 
 
 
 
 
 
X 
Symptom questionnaire 
X 
X 
X 
X 
X 
X 
X 
X 
CBC including platelets 
 
 
 
 
 
 
 
X 
Hepatic panel (AST, ALT, total bilirubin, direct bilirubin) 
X 
X 
X 
X 
X 
X 
X 
X 
Other liver tests (ALKP,  total protein, and albumin) 
X 
X 
X 
X 
X 
X 
X 
X 
Renal Panel (Creatinine, calculated CrCl, BUN, Ca, PO4)**  
X 
X 
X 
X 
X 
X 
X 
X 
Urinalysis 
 
 
 
 
 
 
 
X 
PT/INR 
X 
X 
X 
 
 
X 
 
X 
Serum/plasma banking1 
X 
X 
X 
 
 
X 
X 
X 
HBeAg 
 
 
 
 
 
X 
 
X 
Anti-HBe2  
 
 
 
 
 
X 
 
X 
Anti-HBs2 
 
 
 
 
 
 
 
X 
HBsAg 
 
 
 
 
 
X 
 
X 
HBsAg quant 
X 
X 
X 
 
 
X 
X 
X 
HBeAg quant3 
 
 
X 
 
 
X 
X 
X 
Quant HBV DNA 
X 
X 
X 
 
 
X 
X 
X 
Antiviral drug resistance testing 
 
 
 
 
 
 
 
X 
Ultrasound exam4 
 
 
 
 
 
 
 
X 
Fibroscan (if available) 
 
 
 
 
 
 
 
X6 
*Schedule is used for participants: 
(i) Those who meet criteria for stopping treatment at week 192 regardless of whether   
they stop treatment 
(ii) Those who stopped treatment early due to meeting criteria for treatment failure 
(non-response, partial response, virologic breakthrough); 
(iii) Those stopping treatment early due to an adverse event 
(iv) For those not eligible to stop treatment, visits only occur at study weeks 204, 216, 
228, and 240 
** Renal panel should be obtained at each study visit for participants who are on treatment. All participants should have creatinine tested at week 240 
116mL of serum and 8mL of plasma at week 12, 24 and 48, 8mL of serum and 8mL of plasma at other time points 
2Anti-HBe/Anti-HBs to be done at next visit if HBeAg/HBsAg becomes negative. 
3In participants who are HBeAg positive in qualitative assay 
4If clinically indicated, per AASLD guidelines, done as standard of care 
5A hepatic panel and telephone follow-up (minimal assessment) may replace an outpatient visit if ALT at the preceding visit is <300 U/L for males or <200 U/L females and 
bilirubin is normal (total bilirubin <1.5 mg/dL or direct bilirubin <0.5 mg/dL) 
6Fibroscan (if available) to be performed at week 240 if obtained at week 180 or 192 visits. 


Adult Immune Active Trial                    
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Version 7.0 October 23, 2018 
 
Appendix 5: Participating centers 
 
Bethesda, MD: National Institutes of Health (NIH) Clinical Center 
 
Boston, MA:  Beth Israel Deaconess Medical Center, Massachusetts General Hospital 
 
Los Angeles, CA:  UCLA, Cedars Sinai Medical Center 
 
Michigan Consortium:  University of Michigan, Queen’s Medical Center, Honolulu, Hawaii 
 
Minnesota:  Mayo Clinic Rochester, University of Minnesota 
 
North Carolina: University of North Carolina, Duke University Medical Center 
 
Pittsburgh, PA: University of Pittsburgh Graduate School of Public Health (DCC) 
 
San Francisco, CA:  UCSF, San Francisco General Hospital 
 
St. Louis, MO:  Saint Louis University, Washington University School of Medicine 
 
Texas:  University of Texas Southwestern, Baylor University Medical Center 
 
Toronto, Ontario, Canada:  University of Toronto 
 
Virginia:  Virginia Commonwealth University 
 
Washington: University of Washington Medical Center, Virginia Mason Medical Center